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ENCYCLOPEDIA AND DICTIONARY
OF
MEDICINE AND SURGERY
& li CLVKK, hiMirn>, /jfin
1UU
WILLIAM (JKhKN At SONS
GREENS
ENCYCLOPEDIA
AND DICTIONARY
OF MEDICINE
AND SURGERY
VOL:II
BREAD»EAR
WILLIAM GREEN & SONS
EDINBURGH & LONDON
U
EDITORIAL NOTE
THIS volume carries the subject-matter of the Encyclopedist and Dictionary of Medicine
from BRE to EAR, and the same features which charocteiised the fiist volumo aie
present in it.
In all it contains 1758 subject-headings, and thebe are distributed in the following
manner. Theie are eighty aiticles of moie than 1000 words m length, these include
notewoithy contributions to the subjects of Bronchitis, Eronc/ucctasis, Burn?, Bursar,
Cataract, Che^t, Child, Chlotobu, Cholera, Choiea, Cho/oid, Chmnte, Colon, Colour Visio?i,
Conjmutiia, Convulnons, Cornea, CHtntuw, Cuiettaye, Cystosiope, Deafmutisw, Deformities,
Dermatitis, Jhabetn, Dirt, Dvj&twn, Diyital u>, Diphtheria, Dnty Eiuptions, Dysentery, and
Ear New aiticles on such recent developments of medical diagnosis and treatment as
Cryobcopy, djtoilwijno\ist and DccMonnalion have been added , and Dermatitis Traumatica
ct Venemita in Coal-Miners is dealt with m a- special contiibution
Then, there aie two hundred aiticles of less than 1000 woids, Imt of more than
30 lines (fioni 80 to 900 words) in length, these deal with a great variety of interest-
ing subjects, such as Biomism, Biuit, Btt rial-Pint e±, Calmim, Calcijicatwn, Cental Boats,
Carlo/ ic Acid, Census, Chloroma, Chmaetcru, Cloudy SuclUny, Cocci/godynia, Colics1 Law,
Colporrlwphy, Coma, V'u/il, Consanguinity, demotion, Cydopiti,, Dactyloltjsis, Decline of the
Birth-Kate, Diaw-Reactwn, Dromothuapy, etc, etc
Finally, there are 1478 shoit aiticles and headings, vaiymg m length from 10 lines
to a few words Most of these aie of tlio natuie of definitions, while otheis are references
which seive as definitions I have given special attention to this, the dictiouanal, part
of the work, and have endeavoured to include all the terms in everyday use in Medicine
at the present time , m response to a numbci of requests fiom readers of the Encyclopedia
I have, in some cases in which them seemed to be a necessity for it, added the derivation
of the less familiar woidb, although of couise the teaching of etymology is not the
function of this series of volumes.
I may again be peimittcd to draw the leader's attention to the value of the cross-
refeiences, which aie very numerous and, T trust, quite exact. If he will, for instance,
turn up such a word as DIABETES (on page 319), or CEREBRUM (on page 80), or COLIC
(on page 174), and simply read over tho cioss-refeiences under these entries, he will find
his memory refreshed on many matters relating to these subjects, and may even discover
what he wanted to know without actually referring to any one of the articles quoted
Again, under the heading DISEASE (on page 404) will be found a list of nearly one
VOL. ii v a 2
EDITORIAL NOTK
hundred maladies which are often distinguished by the addition of the name of the
medical man who first described or who specially investigated them, with the briefest of
definitions attached to them
Medicine is advancing with such rapidity in these days, and details are multiplying
so quickly, that it is difficult for any work to keep pace with it and avoid omitting new
terms or methods of treatment , but the iact that the present volume contains a description
of the Drummond-Monson Operation, definitions of Dichotomy, of Delta, of Complement, of
Cleidotomy, of Dw&struw, and of Cordcntery, end articles on Cytodiagnosis, Cryoscopy, and
DecMorinatwn, will show that T have at any rate striven to fulfil my duties as Editor
in this respect also *
J. W. BALLANTYNE
September 20, 1900
CONTENTS
THE CHIEF ARTICLES IN VOLUME II, WITH THEIll AUTHORS
PAf.E
BREATH R Saundby, M I) , LL D , F R C P 1
BROAD LIGAMENT Alban Doran, F R C S 3
BUOMUM II J Dunbar, M D 7
BRONCHIAL GLANDS A F Voelckcr, M D , B S , F R C P 7
BRONCHITIS P Watbon Williams, M D 11
BRONCIIIECTASIH S H Haberbhon, M A , M D , F 11 C P 26
BURNS AND SCALDS A Miles, FRGSK 3*
BURST- A II Tubby, M S , F It C S 39
CAUIIBMA Aloxaiulci J.imcs, M D , F R C P E 44
CALCIUM AND ns SALTS H J Dunbar, M 1) 47
CAPILLARIES The Lite John Duncan, M A , LL D , F It C S E r>l
CATALEPSY Geoigu Wilbon, M D 58
(CATARACT G A Bciiy, F H C S F 60
CATHETERS, USES AND DANGERS o* C W Maiibcll Moullin, M A, M B, F RCS 72
CHEEK, FISSURE OK J AV Ballaiityiie, M D , F R (J P E 81
CHEST, CLINICAL INVESTIGATION OK, DEFORMITIES OK, AND MEDICAL AKI fccnoxs OK CnFh-i-
WALUS F D Boyd, M D , F It (J P E . 83, 88, .md 95
CHEST, INJURIES OF, AND SURGICAL AFFECTIONS 01 CHEST-WALLS J Ci.t\\foid K onion,
M D 90 and 94
CHILDREN, DKYEI.OPMBN p AND CLINICAL EXAMINATION OF John Thomson, M D , F It C P K 98
CHLOHOMA H J Dunbar, ^1 D 109
CHLOROSIS G Lovcll Gullaud, M D , F R C P E 109
CHOLERA, EPIDEMIC Andiew Davidson, M.D , F R C P E 115
CHOLERA NOSTRAS The late A Lockhart Gillespie, M D 125
CHOREA Purves Stewart, M A , M D , M R C P 129
CHOREA GRAVIDARUM R C Buist, M A , M D , M R C P E. 137
CHOREIO INSANITY Maurice Craig, MA,MD,MRCP 137
CONTENTS
PAOK
CHOROID H E. Julci, F.R C.S 138
CIOATRICBS. T. Shcnnan, M D , V R C S E 147
CIRCUMCISION C. W. MacGilhvray, M I) , P K C S E 152
CIVIL INCAPACITY John Chisholra, M A , LL B 155
CLIMACTERIC INSANITY A R Urquhart, M D , F.R C P E. 157
CLIMATE AND ACCLIMATISATION* R W Felkm, M.I) 161
COCOYGODYNIA. J A Kyuoch, P R C P E * 171
COLIC T Runaldson, Ml) , F R C V E 174
COLON. W Halo White, M D , F R C P 1 77
COLOTOMY H W Allmgham, FRCS 187
Coi/)UR VISION T H Bickerton, M R C S 190
CONJUNCTIVA Sydney Htephenbon, M B , F R C S E 203
CONSTIPATION H G Langwill, M D , F R CPE 215
CONVULSIONS, INFANTILE J A Coutts, M D, FRCP 233
COIINBA W T Holmes Spicei, M A , M li , F R C S 227
CRETINISM John Thomson, M D , F R (,' P E 249
CRIMINAL RESPONSIBILITY John Chbholm, M A , LL B 232
CRYOSCOPY J S Fowlw, M I) , F R C P K 255
CURETTAHB J W Balliiiitviie, M T) , F R 0 P E 259
CYSTOSCOPK D Wallace, F R C S E 264
CYTODIAGNOSIS T J H order, B Se , M D , M R C P (Lond ) 2f>7
DBAFMUTISM J K Love, M D. . 271
DBCHLORINATION J IS Fowler, M D., F R C P E 276
DEFORMITIES A H Tubby, M S , F R C S 27H
DELIRIUM TUKMENS W B Diummond, M B , M II C P E 298
DENGUE Surgeon Clayton, R N 300
DERMATITIS HERPETIFORMIH J J Piingle, FRC P. 304
DERMATITIS REPENS H Radchffo Crocker, M D , F R C P 308
DERMATITIS TRAUMATICA, ETC A Whitnold, M D , M R C P 308
DERMATITIS TRAUMATICA IN OOAI -MINERS J Wishart, BSc, M D, ChlJ 314
DIABETES INHIPIDUS F D Boyd, M D , F R C P E 319
DIABETES MBLLITUS R T Williamson, M D , M R C P 321
DIAPHRAGM, AFFECTIONS OF J Giaham Brown, M D , F R C P E 339
DIAPHRAGM, SURGERY OF A. Miles, F R C S E 341
DIATHESIS A James, M D , F R C P E . 348
DIET R Hutchison, M D , M R C P . 350
DIGESTION. T. H. Milroy, M.D , B Sc., and J A Milroy, M.A., M.B. 365
DIGITALIS. H J Dunbar, M D . 383
CONTENTS
I'AOK
DIPHTHERIA. E W Coodall, M T) 385
DISINFECTION E F Willoughby, M D , D P H 405
DRESSINGS C A Stunock, M A , M B , F R C S E 418
DRUG ERUPTIONS R Glasgow Pattwou, F R 0 S I 433
DWARFISM J W Rillantyne, M D , F B C ? E 435
DYSENTERY A Davidson, M D , V R C P R 437
EAR, EXAMINATION OF A Logan Turner, MD, K H C S E 454
EAR, LOCAL AN&HTIIETICS P M Yi-.iisley, FUGS, an I W Jobhon Home, MA, MB,
MRCP (Land) 466
EAR, EXTERNAL EAR Thomas Barr, M D 46G
EAR, TYMPANIC MEMBHANK P M'Bnde, M I) , F 1! C P E 4SO
EAR, MIDDLE EAR ACUTE INFLAMMATION 11 M Johnston, M D, FKCS E 482
EAR, CHRONIC SUPPURATION W Million, M I) 489
EAR, CiiRoNir Nos-SupPURATiVE INFLAMMATION ETC A 11 Choaile, FHCS 508
LIST OF ILLUSTRATIONS
Broad Ligament, The 4
Broad Ligament, Dissection* oi the, and of its Content <• (Plnh) Facing 4
Bionchi — Bronchi tib 14
CathetoiH and Cauteries (Plati ) Facing 72
Cephalhcjcmatoma (Plate) Faciitt/ 78
Ccphalocelo (Plate) faring 78
Chest, Clinical Im ostigation oi the (Plate) Factn*/ 84
Anscultatory Areas
Position of tho Caidiac Onficos in i elation to the Thoiauc Wall
Percussion Outlines of the Lungb Pobtonotly
Percussion Oiitlmeh of tho Lungs Anteriorly
Chest, Arc«i of Cardiac Dulncbs in case of Tcntaiditis with KffiiMon (Plate) ftwny 86
Deep and Supci hcial Dulness of Noiin.il He<ut and Livei
Superficial .ind Deep CUrdiac Dulne&H in Enlargement of the Right Amiile
Superficial and Deep Cardiac Dulness in KnLirgement of the Loft Ventricle
Circumcision Rober's Modification 153
Davies, Colloy's Modification 154
Cloxe-liitch 168
Colour Vision The Young- Hclmholt/ Thcoiy of Coloni-Poicoption (Colonial Plate) Fanny 193
1, 2, 3, 4 diagrammaticall.y icpicbent the ^ iniug-llcliuholtx Theoiy oi Colour-lViception
1 The Red-sensitive substaneo , 2 The (Siccn-buuMtne hiiltotante, 3 The Blue-
bciwitivc biibstance, 4 The Solai Spettium of the Nonu,il Kje The vortical linos
coiicspond to the spectral coloins, «uwl indicate the lelativc degice of stimulation oi
the tlnee photo-sensitive substances — the degiee being piopoitional to the height of
the coloui-uune and the tint of the coloui
5 The Solar Spectrum of the (>reon-bhnd person
b The Solar Spectrum of the Red-blind peibon
Colour Vibion Fig 1 Diagiam illustiating Hcung'b Theory oi Colour-Peiception(C'o/owr«r/
Plttte) . Facing 194
Fig 2 Blue-Blnidncbh actoixhng to the Young-11 elm holt/ Theoiy
Fig 3 Grceii-Blmdnehb „ „ ,,
Fig 4. Red-BhndnesH „ „ „
Conjunctiva, Diseases of (Plate) faxing 212
Acute Ophthalmia
Phlyctenular Conj uuctivitis
Pterygium.
Symblephaion
LIST OP ILLUSTRATIONS
PAGE
Cornea, Diseases of (Plate) Facing 232
Buphthahnus.
Conical Cornea
Interstitial Keratitis
Keratitis Pnnctata
Ulcer of Conica
Cretinism . 250
251
Cryoseope, The , , 256
Curettdtfe, Instrument, for (Plate) Facing 260
Cyclopia 262
Cyclotia 262
Cyllosoiuus 263
Kur, Section thiough the whole extent of the Middle 455
Vcitical Section oi the External Mc.itus, Moinlu<uia l^inp.mi, and Tympanic (-avity . 456
Outer Aspect of Right Tyinjuinc Menibiane, double the natural sue 461
ENCYCLOPEDIA AND DICTIONARY
OF MEDICINE AND SURGERY
Bread.
iny Convalescence) ,
DIUKHIION (CVmrA)
Breakbone Fever.
KEEDIM, (fiiet <lm-
I'mMouM.Y, FOOD AND
I>KM,UE
4 782 \ols> pci cent lens o\jgcu and 4.38
vols pei tout moie CO, than ordinary air.
These liquids |j;i\o the respuatoiv quotient as
(V) 4 3S
' ' = 0905, but this may \aiy under
Breast. Mr MAMMARY ULAND, DIHKANLS
(IK. X«? nlso HANDAUES (the hieatt) , (/HRST, DP-
FOHMITIEH o* , jNPtNr FhH>iN<j (ffuntan Milk,
Jficdtt-Feethny, Weamny, l\fet~Jiui siw?) , MEN
Ml RUATION ( VlCttl lOUs) , I*HYSIOLOO\, Exi'RKllON
(Milk -Secretion)* hiMSNANc'Y, PIUSIOLOGY
(Change* in the Mnmaut) , PREGNANCY, DIA-
GNOSIS, PREGNANCY, MANAGEMENT , PUERPKRIUM,
PIIYHIOLOCH ((W of Jlieaiti), PUERPERIUM,
PATHOIOGY (Affections of Smart* awl Nipples),
SYPHILIS
BreOStpang1. Sec ANMNA PECTORIS
Breast Pump. See PUERPEHIUM, PHY-
SIOLOGY , PUERPEHIUM, PATHOLOGY (A flection* of
Breast* and Nipples)
Breath. S& alw ALCOHOLISM , BROMIBM ;
DIABKTER MKLLITOH (Diagnosis), HEART, M\o-
OARDIUM AND ENDOCARDIUM (Stwtuich Symptom*,
Acetone Odour) , NOSE, EXAMINATION OP (Odour) ,
(ESOPHAGUS (Dilatation of) , RKSPIIUTION, STAM-
VERIKG , STOMACH, DISEASBS OP (tiymptomatolotjv,
Foul Breath) , TOXICOLOGY (Phosphorus, Gat lie
Odour), TYPHOID FEVER (Symptoms) — The
expired air which is popularly known as the
breath consists of atmospheric air returned from
the lungs saturated with watery vapour, and
otherwise altered chemically and physically by
having increased its proportion of carbonic acid
gas, having become warmer, and being charged
with more or less putrescible organic matter
which in certain diseases gives it an offensive
odour, as m some forms of dyspepsia, in ozseno,
tonsillitis, bronchiectasis, phthisis, pulmonary
gangrene, and typhus fever, It normally con-
VOL, u
I noi uial conditioiib These chemical changes are
I the immediate lesult of the e\chanjre of gases
i in the lungs &"d lemotcly depend upon the
vi Ul exchange which takes place in the tissues
(vtde " Kebpiratiou ") Expired an also contains
traces of ammonia fiom the blood and trace* of
H and CH4> probably derived fiom the digestive
tnict, whence also come such products of de-
composition iu- acetone, which gives a peculiar
and characteiiHtic odour to the bieath This
odour has been mobt often observed in diabetes,
but tis acetone is found in the urine after taking
alcohol, m pneumonia, meahlcb, and other acute
diseases, especially m children, it is um>afe to
attach to it any great diagnostic value, but
undoubtedly its presence would suggest the
desirability of a careful examination of the
urine
Sulphuretted hydrogen, if formed in the
stomach or small intestine, is excteted through
the lungs, as are the vegetable volatile sulphides
found in onions and garlic Foul-smelling bi eath
is perhaps rnobt often dependent upon putrefac-
tive processes in canons teeth or among the
papilla of a coated tongue The normal tem-
perature of the breath is 36 3 0 , *hich is very
ne.ii the temperature of the body. External
cold increases the intake of oxygen and the dis-
ci mige of carbon dioxide, while a rise of external
temperature is followed by a diminution of both.
Muscular exercise acts like cold, and un-
doubtedly a considerable part of the effect of
cold is duo to the involuntary movements
excited by it
Food produces the bame result, while fasting
lowers it In the case of Cetti, the fasting man,
BREATH
the absorption of oxygen and discharge of carbon
dioxide per kilo, of body weight fell rapidly, so
that the respiratory quotient which before the
fast was 0*73, on the third day of fasting had
fallen to 0 65, and remained during the remain-
der of the fast between 0 65 and 0 68 Vegetable
food raises the respiratory quotient to nearly
unity, while on flesh diet it is about 0 74, find
on a mixed diet somewhat highei, these
differences depending upon the amount of car)>on
present in the food
The relations of the breath to the ettolnyy of
disease are not perfectly clear, but it is known
{a) that animals made to rcbrcathe the same
nir die ultimately of asphyxia , and (6) there IH ,
consideiable volume of evidence to show that
persons living in crowded <ind ill - ventilated
rooms, \\heie they aie compelled to breathe over j
again air which has been already exhausted by ;
themselves and others, become anemic and ill, i
and are especially liable to become attacked by
tuberculosis , (c) the tulierclo bacillus has lx)en i
found in the expired breath of consumptive i
patients, so that doubtleNw it may afford a
channel of infection for thib and for other
diseases. It is believed that measles, scarlatina,
diphtheria, influenza, and the infection of a
common cold may be communicated by the j
breath — a matter of the greatest importance in
reference to prophylaxis
A good deal of discussion has taken place a« ,
to the causes of the asphyxiating property of air •
vitiated by respnation, and the subject is con- •
sidered in the article " Asphyxia "
Clinical Dtagnoti* — Examination of the ,
breath may be utilised foi purposes of dia-
gnosis —
(a) For] the detetnimation of death it is a •
common practice to apply a feather to the
mouth or the nose, or the polished surface of a
mirror, m ordci to see whether any movement
of air or deposition of watery vapour takets
place
(6) The temperature of the breath vanes with
the body temperature — for example, falling very
low in the cold stage of cholera and rising high
in fever
(e) The odour of the breath is modified by
smoking or chewing >anous aromatic substances,
or by eating certain aiticles of food, such as
garlic, which contain strong-smelling compounds.
Alcohol gives a chaiacteristic odour to the
breath, as do many substances used as dings —
for example, bismuth, copaiba, and the mineral
poisons, especially rneicury The bieath of
women dining menstruation may have a sweet
odour like that of chloroform In uraemia the
breath often smells of ammonia, which may be
demonstrated by the production of thick white
fumes when a glass rod dipped in hydrochloric
acid is brought near the mouth, while in diabetes
its odour has been variously compared to luiy,
apples, sour beet, and vinegar. In pycemia and
allied conditions (septicaemia, etc.) the odour of
the breath is sweet In dyspepsia and constipa-
tion the breath is foul and sometimes almost
fttcal in odour, while, when stercoraceous vomit-
ing is present, it is undoubtedly f fecal. Local
morbid conditions, such as dirty or decayed
teeth, ozfleua, chrome folhcular tonsillitis, catarrh
of the mouth and tongue, ulceration or gangrene,
malignant disease, canes of bone in the mouth
or nose, ulceration of the larynx or decomposition
ot retained bronchial secretion in dilated bronchial
cavities, or gangrene of the lung, may give rise
to the most foul (xloins of decomposition in the
bieath
(r/) Microscopical examination oi the expired
air haw in phthisis shown the presence of the
tubercle bacillus (A Ransome), and if applied
in other diseases might Micceed in demoiiHtrating
othei pathogenic bactena, but this method has
not so far been veiy extensively used Many
authorities consider 'that the tubercle bacillus IH
never found in the breath in ordinary respna-
tions, but only when associated with the act of
coughing
(e) The same may be stud foi bacteriological
examination, this mode of seaichmg for microbes
not ha\mg been systematically applied to the
breath
(f) Chemical examination is the ouU scientific
method which h.is hitheito yielded much result
The respnatory quotient is found to vai\
ace 01 (hug to the state of metabolism of the
hod} . in inanition it IH diminished, while in
teitain wasting diseases it is increased There
is said to be an increase of (JO, in asthma and
bionchitis, *hile in cholera there is a decrease
In Bright's disease and uremia the ammonia
is greatly increased Marsh-gas may be cxpued
in hiuh quantity as to make the bieath inflam-
mable, and several instances have been recorded
wheie the patient has accidentally wet fin; to his
bieath, for instance, when tiymg to light his
pipe Such patients ha\e generally suffered
from dilated stomachs, in which decomposition of
food was associated \i ith the formation of this gas.
In diabetics the bieath sometimes contains
acetone In poisoning from hydrocyanic acid
this acid is present in the expired air
Treatment — As evil-smelling breath is gener-
ally a secondary symptom, its treatment depends
for the most part upon the removal 01 cure of
the primary condition, and it would be out of
place heie to do more than indicate the hues
of treatment Where the seat of the disease is
in the mouth it is accessible, and carious teeth,
etc, should be stopped or removed, a coated
tongue scraped or disinfected, the pharynx
sprayed with an antiseptic solution, etc. For
oztena the uso twice a day of a nasal douche is
often the only remedv
In acute diseases, where the mouth is foul with
sordes, it should be cleaned with glycerine and
rose water. The foetid odour from bronchiectatic
BREATH
cavities and gangrene of the lung may be kept
down by crcasote taken in capsules T>r. G
Vivian Poorc has recommended garlic for thin
purpose, in the belief that this vegetable con-
tains an antiseptic principle to which it owes its
reputation as an article of diet In two cases
of the kind wheiem a trial was made of Di
Poore's suggestion, the stench uas diminished,
and was curiously enough not replaced by any
offensive smell of garlic
Putrefactuo changes in a dilated stomach
can be most efficiently heated with lavage b\
means of a soft stomach tube and a, tepid solu-
tion of sahcylato of boda (1-1000)
The value of hot intestinal irrigation in
urtcnna .ind similar diseases has yet to be
determined, but is at least \\oithy of a fan
trial
Breathing. *SVr CuiiimbN, CLINICAL
EXAMINATION OP (lirtntfnnti) , H\SIERU ,
PlIYMOLOm (Reipltatton) . RESPIRATION
Breath lessness. Xee \>\ MS<X\ , HEAI« ,
MYOCARDIUM VND ENDOCARDIUM ( Symptoma-
toloyy, Dyijnwa) , RESPIRATION , et<
Breech Presentation. &? LABOUR,
DIAGNOSIS VXD MECHANISM (frxlfitu Liei) ,
LABOUR, MAV\(,KMBNT OF
Bregma.— The antoiioi fonUnelle of the
head in infants and the place 1 01 icspouding to
it in adults See LVUOUR, PHYSIOLOGY 01
(Paisem/en, Foetal Head)
Brenner's Blood Test.— F.uime of
the red colls (in dialxjtit blood) to take the led
stain <is the noimal corpuscles do *SVe DIABETES
MBLLITUS (Coma, Dtaynout, of)
Brenzkatechlnurla. - Bicn/katcchm
(or alkapton) in the mine See ALKAPIONURIA
BrephO-. — Biepho-, as a picfix, signifies
" pertaining to an infant 01 foetus," and is used
in such words .is BHEPHOTROPHIUM, a foundling
hospital , RREPHOCACOTOLPIA, \ulvai gangrene
in infants, BKKPiioFOMiAR<'iA,obt»mt\ in infants,
etc
Breweries. See \MOHOL (Kee>)> Toxr-
COIXKJY (Jrwnir)
Bricklayer's Cramp. -Spasm of the
right hand fioni holding the trowel See SPAHM
(Halnt)
Bridge Work.
Bar Work)
See TKETH (Bridge and
Brighton. <SV<* THERAPEUTICS, HEALTH
; REHOHTS (English)
Brlckworker'sAncemla.
SITB8 (Unanana).
Brides- les- Bains. 8™ BALNEOLOGY
(France)
Bridge Of Allan. See BALNEOLOGY
(Great ftritam) , MINERAL WATERS (Munated
Saline)
Brlght's Disease. «sv
See also ANEMIA , BRAIN , BRONCHITIS, ACUTE
(Causes) COLON, DISEASES of (Colitis) , CQN-
• JU\<TI\A, DISEASES OF, Cou«m, EAR, OTITIS
^ MEDIV ((Rinses), ECLAMPSIA, HEARI, MYO-
I CARDILM AND ENDOCARDIUM (Ettofoffy, AfttScle
. Failure), HYDRoPvrin , INTESTINES, DISEASES
OF (Entet ttn)9, LEUCOCYTOHIS , LUM.S, VASCULAR
DISORDERS ((Edema), MENSTRUATION AND ITS
DISORDERS (Amenwrhtrn) , OCULAR MUSCLES,
AFFKCHONS OF, PERICAKDIUM, DISEASES OF
(Pencaiditis) , PERITONEUM (Acute Pet itonitis) ,
1 PLEURA, DISEASES OF (Acute Pleurisy, Jffydio-
1 thorax), IJLLSE , RETINA AND Omc NERVE,
I STOMACH AND DUODENUM, DISE \SESOF; TINNITUS
I AURIUM
Brim Of Pelvis. See (JBVERAIION,
KKMME OROAXS OF (Owmt* Pelmi)
Briquet's Syndrome.— A group of
symptoms, including shortness of breath, sup-
pression of the voice, and painlysis of the dia-
phragm, occuiring in hysteim
Brlttleness of the Nails. <*<•
NAILS, An-ErnoNS 01
Broad Ligament, Diseases of
the.
, DlMPLAl hMEMS 01 .J
I INFLAMMATION t
MESOSALPINX
MESOMEIRIUM
TUMOURS i
MESOSM PI NX
MESOMFIRIUV
I See nha ECTOPIC (TEHTATION , FALIOPIAN
TUIIEM, O\ ARIES, DISEASES OF, PELMS, DIS-
EASES ot niK CEILULAR TISSUE, PUERPERIUM,
lJm»ioLo«,\ , I'-IERUK, DISPLACEMENTS, etc
| THK seious fold kno\Mi .is the broad ligament
I is divided into the mososalpmx 01 mesentery of
I the Fallopian tube and the mesometimm pioper,
! which lies below the le\el of the attachment of
the ovary In disease the nu»sosalpm\ is mainly
associated \vith tumouis, the mesometrium with
inflammatory deposits
Dt*pl<icement of the Fold* of the Broad Liga-
ment by Twnour* — Paio\aiian eysts, cystic
tumours developed m the hilum of the ovary,
and, m raie instances, tumours of the ovary
proper, make for themselves a capsule of the
mesosalpmx, which they gieatly distend. This
condition is easily recognised during operation
by the position of the Fallopian tube, which is
much elongated and stretched over the top of
the capsule. These same tumours sometimes
]S, Curved Inl.uli's.
O, IM«- (ivarii.
. ll.'.lii.--d ..,,,-tl.iril.)
An
A. Vn-ii.-.il iiilnil.-s. .MUM., ln-jinrlirtl.
I',. Srs.-ilr .'V.-l rolllHclr.i willl Vrrl.i.r.ll
ml. ill.'.'
c, DII.-I ,,r«;;1vinn.
1), hillnpiaii tul»-.
K. Srssilrt.-nninal.'Vr^MlMii.'t ,.r ( ia rt II.T.
ll'. Pr.lniinil.-iir.l ',-vsl rn'.ni nil. nl. -s ..I'
Knhflt.
(Natunil si/.-..:
DISSECTIONS OF THK BROAD LIOAMKNT AX I) OF ITS CONTENTS
(At'tur PI.YU.ANTVNB and .1. D. WILLIAMS)
BROAD LIGAMENT, DISEASES OF THE
toma may bunt Fatal mtraperitoneal hemor-
rhage is in either case very probable Should
the hamatoina remain stationary, it is not likely
to suppurate The heematoina associated with
Extras-uterine Pregnancy is described under that
heading (vide- " fictopic Gestation ")
TUMOURS OF THE BROAD LlGAMKNT (1) Of the
Mesosalpinx — When the uterus is the seat of a
large fibro-myoraa, and in ceitam othei con-
ditions unolving obstruction to the lymphatics
of the pelvic visceia, large yellow blebs 01 bullee '
of irregului form are often been covering the
mcsosalpinx These " lacuuar cysts " or " sub-
serous hygtomas " do not in themsehcs endanger
the patient, nor do they interfere muih with
opeiative manipulations , they are simply im-
portant as usually indicating serious complica-
tions else \\heie
Anatomically the simple parovarian cyst is a
true tumom of the mesosalpinx, and so are all
papillomatous cysts developed fiom the paro-
vanum, and from that poitmn of Gartner's duct
which lies within its folds The diffeient ways
in which the folds of the mesos.il pmx may be
opened up by tumourh horn othor jMits is de-
scribed above
Small tatty tumours, pedunculatcd or sessile,
have been detected in the mesosalpmx, which
oiten contains <i httlo fat Parana's case of
lipoina of the tube \\as possibly a f.itty tumom
of the mesosalpinx surrounding the tube
(2) Of the M emmet mint — Thi* part of the
broad ligament may be the seat ot A fibroma en
jUtro-myoma developed quite independently of
the uteius, from the hbious and muscular tissue
in its folds A tumoui of this class may attain a
great size, and pi ess upon the vessels and wives
of the pelvis and on the uietei No othci kind
of abdominal tumom displaces peritoneum moie
widely or more freely In compaiison \\ith
uterine "fibroids," these mesomctnc hbro-m\o-
mas develop in youngci subjects, large growths
of this class having been iemo\ed from \tomen
under thirty yeais of age
" Fibroids " originating in the uterus, espci i-
ally near or m the cerviv, tend to burrow into
the mesometiium They then lie Neiy close to
the ureter. In exceptional cases that duct has
been found passing ou'i and not under the bur-
rowing tumour
There is often much fat in the mesometiium,
and hence it is not surprising that hpoma of that
fold has been recorded. Sat coma has also been
observed Freund describes a case of extonsno
invasion of the bioad ligament with echtnwocci
Broadbent'S Law.— The hypothesis
that bilaterally associated movements are repre-
sented on both sides of the brain, and that the
closer the bilateral association the more nearly
equal is the representation on the two sides of
the brain See BRAIN, AFFECTIONS OF BLOOD-
VESSELS (Paralysis from Vascular Lesions)
Broadbent's Slam.— One of the dia-
phragm-phenomena m adherent pericardium , a
visible retraction of the thoracic wall, well seen
on the left side posteriorly between the eleventh
and twelfth ribs , it is due to the systolic tug
of the heart communicated to the chest wall
along the lines of attachment of the diaphragm
Broca'S Convolution* See APHASIA
(Anatomical Introduction), BRAIN, PinsiOLom
oy (Function* of Ceiebral Cotter) , PHYSIOLOGY,
NKRVOUS S\ STEM (Cerebrum^ Discharging J/JrAan-
t*m) •
Brodle'S AbSCeSS. See KNEE-JOINT,
DISEASES OF (Pyogenic Diseases, Chronic Osteo-
myehltt)
Broiling1. See BRANPERTXU, INVALID FEED-
ING (Gtneial Preparation of Meat*)
Brom-. — As a pieh\ Broni- indicates the
piesence of Inomnie m various chemical com-
pounds, such as Hromacetal, Rromacctamide,
Brouwcetic Acid (mono-, di-, and tn-), Brom-
.icetones, Bromacetyl, liromacct} lene, Brom-
Acryhc Acid, Bromacbpic Acid, Bromalbumin,
Bionialdehydo, Bionializannc, Biomallyl, Brom-
cil<nn, Bromamide, Bioni.iniylene, Bromamline,
Bromamsol, Btonibenzcne, ]iromlx>n/oyl, Biom
catfcm, Bromcinnamie Acid, Biomethyl (Hydro-
bromic Kther), Brometono, Bioiuludtin, Biom-
hydioqumonc, etx
— From the (iicok fipupa., signifies
ioorl, especi.illy solid , also a proprietaiy pre-
paration (like chocolate), also as a prefix in
such viords a* BHOMATOLOCIY (dietetics), BKOMO-
(JRAPHY, and BltOMATOMETm
Bromal Hydrate.— A substance, ctys-
talliiie in character, sm.ilai to chloral hydrate,
acting as a narcotic, and tending to slow the
pulse and the lespmition, used in epilepsy,
chorea, etc , in doses >f 1 to 7 grams
Bromal bum In. — A preparation used
m epilepsy, etc , and consisting of bromine and
albumin
Bromatoloffy. <sv« DIET
BromatOXlsm.— Poisoning by food,
<•/ alUntmsis, botulism
BrOmhldrOSlS. foe BROMIDIIOSIH
Bromide. ^ BROMUM.
Brom Id la. — A propnetary preparation,
containing chloral hydrate, bromide of potas-
bium, and the extracts of cannabis mdica aud
hyoscyamus , it acts as a hypnotic
Bromldln. — A propnetary preparation,
acting as a hypnotic, and said to consist of
chloral, eannabis mdica, and hyoscyamus.
6
BROMIDROSIS
BromldrOSlS.— A diseased condition of
the skin, in which the swe.it assumes a foetid
odour (fipfofjMs, a stench) In btoinohypendtosw
the sweat is excessive in amount as well as
offensive in odour Set SM\, J)ISK\SKS nt
SWBAT \ND SKBAfKOUS (.HMV,
Bromine. >v*< BHOMUM
Bromiodoform. — A substitution <om-
pound of biomum and lodofoim
Bromfpln. -A solution of biomum in
oil of sesame, used as a hvpnntu in epilepsv,
choica, neuiasthema, and hvstcua'(dosi, half to
one tcaspoonful)
Bromfsm. Me «/s« KFII.MM (Malicnml
TttatmfHt) l'iMKMACoMXi\ . TOXIWI«MI\
The teim biomism js applied to the senes of
symptoms that aie met with lesulting tiom the
excessive use of one ot moie of the biomine
compounds Since thcdis(ove»v of the sedative
influence ot the bionndes on the icntial neivous j
system, these lemedies have been veiv e\ten- |
sively used foi many neivous disoideis, .ind it ,
is specially in chiomc neivous cases, < <i epilepsx, '
that, the untowaid etlects ot the biomulcs ate
seen The degree ot toleiance toi bionndes
xaiies, as foi othei medicinal ictnedies In I
some cases the continued use- of even small \
doses — ."> to 10 giains — leads to a manifest ition t
of the ininoi 01 majoi symptoms ot bromism, ,
while in othci < ases vei v lait;e doses ue toh i.ited I
even foi lengthened peuods Houston leeoids !
an mteiestmg case (vol i p fi8) of a boy ot
eleven tolerating 60 giauis daily foi two veais
The natuie of the disease and the idiosj m i asv
of the patient .tie the impoitant modifying
factois
The depiessing mtlueiue oi the bionndes on
nerve and muscle (ells, taken with then init.it
ing property dining excietion by the usual
( hanncls, is responsible foi the symptoms of
biomism These mav be hiicnv summarised as
follows —
JieiiHt-iHuvutni Ny\ftm -A diminished (ap.i
bihty foi physical 01 mental woik, with o«a-
sional headache, which may be of a seven-
chaiuctei and ( hicfly in the fiontal legion, aie
the enihei symptoms Latei, slight foigetful-
ness, diminished mental (apatitv, ueneial weak-
ness of mental faculties, diminution of the j
palatal and phaivngcal leilex. and in still latei !
stages some distuibaiuc oi gait mav be piesent |
In not a few cases, howevci, especially m
epileptics, the hisl symptoms aie those of an '
nici eased exeitabdity of the biam coitc»\, amount-
ing even to mama (Hiomomama) The develop-
ment oi any such symptom in these (ases should
theiefoie lead the pi.Ktitionei to a laictul
surve\ as to the doses and duiation of the tieat- |
ment
Cnnlio- vawtthn tfyttem — Along with the
geneial muscular depression thete is more oi loss
evidence of general cardiac cnfeeblement The
heart's action la weak and the pulse feeble The
rate may be slightly diminished 01 nici eased A
few cases are rccoided where death has been
attributed to the stoppage of the heait in dia-
stole as the lesult of excessive use of the drug
Other indications of Aasomotor disturbance may
be picsent, ?</ cold extremities and clammy
state of the skin
Cutaneous tiyvtem — An <uiie eiuption, most
maikcd on the toiehead, neck, face, and tiimk,
is futpiently the earliest symptom to attiact
.ittcntion In other cases the eiuption may bo
erythematous, scailatitoim, pem]>higoid, oi even
inpial in n. i tui e In cluldien the eiuption may
pass fioin a disci ete acne t)pe to tike on a
papillomatous appeal .nice
Othft »Sys^f//»s The moie nnpoit.int s^mp
toms eii( ounteied in the othei sv st ems aie loss
oi appetite, ioul bie.it h, aiuumia, dilatation of
tin1 pupil, diminution ol the lespnaton tate,
and slightly depressed tempeiatuie
Ticntintnt - I'lophvLixis is all impoitant \
lull ie(ogmtion of the phaimaeolomr.d aetums
ami utu etui obsei \ation oi patients using these
lemedies, noting espe( ialh the condition ot the
skin, miuous membi.ine, .ind gcncial \ittl (aj)«i-
cit\. Null suHut in all (ases to pi event the de-
velopment of the (ondition in am si eat degiee
Cuntne tieatment lesolves itself into ••
stoppage of the ust of the ding, stnct attention
to the action of the skin, kidne\s, and liowels,
and the use of gemial tonu lemedies ll^duv
theia])eutic measuies aie ol gie.it assistance,
both fiom then local and geneial etlci ts Small
doses oi ai, sen ic gnen in combination with the
bionudes aie of some seiMtc m diminishing the
tendeii'-v to biomism Liq aisemcahs is the
form most lonimonlv used, but SOUK wnteis
behe\e that aisemate of soda is the most useful
piepaiation, being less hkch to piodiuc .inv
gastnc intestinal nutation
Canuabis indiea is also fie(juentl> used along
with the biomides with the o)))ect of diminishing
the tendency to the pioduction of untowaid
distuil)aiues ot the nervous s>st<m
BrOITIOCOll. A combination of I >t onnne,
tannin, and gelatine , it is thought that the
In onnne is not set lice till the medi< me leaches
the intestines, it has been leconmicuded in epi-
lepsy and (externally) in lichen and ec/ema
Bromoform.— An anesthetic and hvp-
notic mcduinc (('INUJ having iea(tions simi-
ln to ihloiotoim
BromOl. — A piopnetary pie]).tiation , dis-
infectant .ind caustu , tiibnnnphenol
Bromomanla. x
Bromomenorrhoea, — An ottensivo
condition of the mviihttu.il dischaige ,V«» MBN-
hlRUAHON \\1) I'lS DlSOKDERS
HROMOPYRIN
Bromopyrln.— A mixtuic ot antipyrme,
caffeine, and biomide of sodium
. — A bromum substitution
compound of otcin, which is a homologuo of '
i osorcm
Bromum. ,SV<> «/w AM-MIU^IX (lltnm-
nhof Ethyl), BKOXIISM, CONMJI SIONS, INJ-AVIIIF, •
PKUO KiibPiuiNH (Jhomtue) , KIMI hrs\ , Ilu*-
N01KS, PjlARMAt OIXMA , etc — TliC action ol *
bint/line is Sinn l<u to th.it oi chloimo <ind iodine
It is rarely used in medium', <uid is ot impoit-
ance solely as the source of the bromides 1
]*otnwn Hi omul urn is <omj>osed ot colourless
glassy (ubos, frecl} soluble in watei Dov
")-.iO gis 2 Swlii JitomH/uui is a powdci made
up oi small xv Into tuba ci xstals, soluble 1 in 2
ot water Dose — V.'JO gis .'i Aninioini It t om-
nium consists oi small (olomless cubic ciystals,
soluble 1 in \\ oi \\atei />ost -3-30 gis 4
A<nluin II i/il)oln own nni DiliitHin, a colouiless
lumid pie}jaied tiom potassium biomide J><*<
— l.Vhl) in Uiomides .no admimsteied xvhcn-
e\ei it is wished to diminish loflex e\citabiht\
of the neivous s\stem Fomiuilx tin) woie
applied in st lolly; solution (hi ei tly in phaixnaeal
diseases associ itcd \\ith spasm, and he ioi e m.ik-
mg a lanngeal ex.imm.ition , but (oe.nne has
taken then place tni these pui poses IIIIUMX
fins diseases, <n eompamed b\ lomulsions, thin
action is almost spe<ih< I'oi < pilepsy, giadu-
.ilh mcicasing doses ol potassium biomide
should lx» iriNen until a dose is ie idled which
j»ives tho maximum beneiit, and then the .ul-
innnstiHtion ma\ be continued mdehniti^h \
jjood way is t<» u;i\o the wlu>le duly amount in
one dose at bedtime Sometimes as miuh as
Jdrs pci d«i\ may be le^uned, but no fixed nile
.is to dosage e.in be laid down When lai««e doses
ha\e to be p\en it is well to oidei a mixture oi
the tin ce biomides In most cases a diminution
ot the numbei oi sei/uies is ill tint is achiexod ,
but should the iits disappeai alto^cthei the use
of theluoundc must be (ontmued ioi months m
the hojM* that a c me ma\ bueilc<tcd Biomides
have little ctleet on /iettt mal In tetanus xciy
larj»c doses aie lequned if any j;ood is to lesult
-say 60 <»is eveiy two houis In delnmm
tiemens biomide is iiixalu.ible, and is usually
administciod in conduction with ( hloial hvdiate
In cases of sleeplessness due to worix, ox*cixxork,
01 climacteiic disturbances a small dose of a
biomide is a most etheient hypnotic but it is
of little serxice li the insomnia be caused by
pain 01 oi^amc disease " Hromidia," a pio-
pnctary mixtuie consisting of potassium biom-
ide, chloial, cammbis mdua, and hyoKcyamus,
is much used as a hypnotic In the sevcie
headaches of migraine, biomides may bo the only
di ugs cajMible ot affording lehof and they aie
also useful in bomo foims ot neuralgia In chil-
dien they aie much used foi convulsions of a
leftexnatme, but they die contra-indicated in
choioa, unless the moxementR are excessively
Molent, 01 aie associated with sleeplessness 01
noctuinal icstlessness Ammonium biomide is
useful in whooping-cough Jfconi'des .ire lecom-
meudcd ioi palpitation, espociall\ wlien due to
functional disoideis oi the hcait Thetx are in-
dicated in cases ot incontinence ot mine, the
lesult oi spasmodic contraction oi the hladdei
They aio also xeiy efficient tinaphiodisiacs
Andum lfi/<hnhionuuiTH Dilution is smnlai in
action to the hionudes, but cannot be taken
ovei siuh a lung ponod, on account ot the dis-
tm banco oi digestion caused bv the ,md It
has been stiongh adxoeated toi trifling heait
disoidois associated with p.dpit,ition and uneasi-
ness, and is said to relieve noises in the eais in
some cases Biomides ot mlutun, lithium, and
vtHJtifmm have been used at \aiious times, but
they ha\o no leal adxantagos oxei the ottici.il
salts
Bronchadenitis. inflammation oi the
bionohial ulands fftt JiitnMiii, Bimxc HIAL
(li \M>S
Bronchi, Diseases of.— The affec-
tions of the bionchi and assoc latod ulands aie
desciibed in the follow inu aiticles
1. Bronchial Glands
2 Bronchitis (foi Capill.ux Bionchitis w
" I'neumoma )
3 Bronchiectasis
4 New Growths. *« "Lungs" and
" Mediastinum
Bronchial Glands
AN \ioxn 7
MORHID \\vioxn \ND I'AUIOIOM S
SIMMOMS \M> Pinsic \i SIC.NS 9
DIAC.XOSIS 10
Till A I Mt NT 11
»S*i» «f*o COLC.JI (( 'I i Html I'nmttt*), Lt NC,,
TLJM-KCI msisoi (Putholo(ji«il Anatomy), LI.N(,S,
VllMlssni , taMI'UUK SlKIlM, I'lllhlOKMiY AM)
INlllOKH.X , Ll\»H (.1/jscfKx (it) , Mfcl>IAMIM.M
A \ iifMM The glands nitiy be classified into
tlnoo main gioups (Baietv) —
(i ) Those aiouncl the lox\ei end oi the tiachca
ancl the main In one hi — the peii-tiaeheo-bionc hial
glOU])
(n ) Those between the main bionchi, clueih
beiu'ath them the mtc'i - tiac heo- bionchi.il
gioup
(in) Those between the dmsions oi the
bronchi — the mter-bionclnal gioup
These three gioups aie in connection xvith--
(i ) Tho superficial and deep lymphatics of
tho lungs ,
(11 ) The lymphatics of the Msooial pleuia
(in ) Some of the lymphatu s of tho oesophagus
Those lymphatics communicate tioely
BRONCHI, DISKASES OF— BRONCHIAL GLANDS
The glands themselves vary A good deal in
size and shape, and the inter-bionclual group
extend for some distance into the substance of
the lung, according to ('ruveilhici, as fai as the
fourth diMsions of the bronchi The light
bronchus is shorter than the left, and is 111010
directly a continiution ot the trachea than is
the lett, and there are a larger number ol glands
in connection with the right than with the leit
bronchus
From the position of the glands it will be wen
that they (onie into relation with tlie following
inti a thoracic structures — '
The trachea, the bronchi as fai OH then iouith
division, the lungs, the puhnonaiy arteries .ind
veins, the Mipenoi \cn.i ea\a, the innominate,
subclawan, and a/ygos MMIIS, and the aoita , the
vagus nerve and its lecurrent blanches, and the
pulmonary plexuses, the pemaidmm, ami the
oesophagus
The tiacheal bifuication cone sponds in level
to a honxonttil line drawn tliiough the junction
oi the inaiiubrmui and bod\ of the sternum ,
this coi responds behind to the spine ol the fourth
dorsal veitebra 'I he lioii/ontal li\el at the
point ol intersection of the lines ton esponding
to the spines of the scapulu: will also gi\e ns the
level of the traoheal lutuiiation
Afonmi) JA tniVY \M> PIIIIOKH.I — The bion-
clnal glands may be the seat ot xaiious morbid
changes, either as a piimai\ condition, 01 second-
ary to changes in the neighbouiing paits fioin
which the lymphatic s pass to the glands, or as
partoi some gcncial condition attccting the lym-
phatic glands
The mobt common moibid e ondition is j
tofio/t, and in adults this condition is piacticalh
constant Next to pigmentation, h yprt <rinui and
inflammatory swelling of the glands are the most
common moibid conditions, and are met with in
association \vith similar conditions in the plenia,
lungs, and biouchi The amount ot swelling
may be consideiable, the glands being three 01
four times then noimal si/e, pinkish grey in
colour and sueculent, oi, in cases where the
spelling is maiked, becoming pale gie> and
medullary in appeal am e The enlaigemeut is
not so important as the .iccompanving lowered
activity of the glands, \\ Inch results in diminished
lesistance to invasion oi the tissues b\ micro-
oigamsms, moio especially \i\ the* bacillus tulm-
culosis It is cjmte probable that cnvmg to the
letaidatiou oi the hmph stieam in the lungs or
pleuia, the bacilli ha\e a longer opportunity of
getting into situations suitable foi the»n gio\\th
and multiplication
In this wa} tlie iiequency ot tul)eiculons dis-
ease of the glands aftei measles and whooping-
cough may be explained That these changes
in the glands aie not necessaiily secondary to
tul>eieulouh disease oi the lungs 01 pleuia is
evidenced by the fact that we often hnd the
changes m the lungs recent while those in the
•- I
glands are obviously of long standing, and if we
find in a given case the region of the loot of the
lung to be the part most affected, it is most piob-
ablc th.it the disease originated m the glands
and spiead cmt\\aids Tho frequency oi casca-
tion ot the hi one hial glands is shown by the fact
th.it in a seiies oi 300 post-moi terns mode on
childien undei twehe ycais of age the wrrte*r
found the bionchml glands caseous m 110 t e
in 37 pel cent ot the cases Sue h glands may
imdcigo \arions changes, bee-oming iibiosed or
calcined, 01 the1} may undeigo sot ten ing 01 sup
pin ati on
Casoation oi the glands is usually associated
with a tuberculous k-sion m tin1 lungs 01 else-
\\heie, but may be the sole tubeiculous mam-
iestation picsent An .inalogous condition is
met \\ith in the abdomen \\hen \\e find caseous
mesenteiu ul.inds as the sole tubeiculous lesion
The \\ntei belu^es that taseous bionehial gl.inds
.lie moie common than c.iseousmesentei ic glands,
thus indicating th.it tuheiuilous infection takes
place more fiequentH thiimgh tlie an-pussages
than the alimeiitfii \ tiact
Apait horn tubercle1, met.ist.itn1 deposits in
the glands aie oi iicquent oeeuirence in associa
tion \\ith malignant ck'])osits in the> lungs, ple'ui<e,
and eesophagus eithei ol apiunai\ ot secondai}
natuie
l>llllhll^ ne\\ i>io\\ths in the gl.inds <ue most
eonnnonh ol the nature of saicomaU, e>s]uciall\
1^ mpho-sai < omata (\tt " jMe'diastmuin ' )
In 1} mphade'iionm (y v) the- bionchial glands
take pait in the general glandular enlargement
In both seeondaiv and teiiti,u> s>pluhs the
bronchial glands m«»> share in the* genei.il glan-
elulai enlargement
When wax v disease is \\idespmid the glands
throughout the body m.iv be tlie sent oi deposits
ot waxy material, but it is verj doubtful li an}
di-,tin < t s\ mptoms or physical signs can be tr.i' ed
to this condition m the bionchial glands
Disease of the bronchial glands pux luces
enects in two \\a}s -
(i ) liy impairment oi t unction
(n ) Hy the prrxluction oi cnlamement with
consequent ]>ressure effects
The effects of nnpaiied function ha>e l>een
briefly re^ferrc'd to above, and are more fullv
dealt with under the head of tuberc ulosis Prac-
tically, enlargements oi the bronchial glands mif-
ficient to cause pressure effects are due to eithei
tubciclcor new growths, and the former is infin-
itely the more common in children, the latter in
adults Although disease of the bronchial glands
is not uncommon in adults, it is chiefly in
children that definite symptoms arc caused, and
the subsequent remai ks refer chiefly to them
Pressure effects ma} be exercised on the fol-
lowing parts — (i ) The trachea and bronchi,
(n ) the lung , (in ) the blood-vessels , (iv ) the
nerves , (v ) the oesophagus , (vi.) the peri-
cardium
BRONCHI, D1SKASKS OF—BRONCHIAL GLANDS
9
(i) Prewure on th? Ttaehm attd fitowht
Some degree of tun rowing 01 displacement is not
infrequently seen In othoi cases inflamma-
tory adhesions with the \v«ill ot the tiachea 01
bronchus develop, and in tins way a path is
opened up foi tho inflection of the an-passagcs
xvith tuboicle IVifoiation of tho an -passage* is
not uncommon In 800 autopsies on children
it was present in "23 cases, if oxoi '.\ pel cent
The light bronchus is innio frequently peifoiatod
than the left This niuv l>e due to the shoitci*
length of the light hionthus, and to the lai^oi
numbei of glands on that side The tiac hea is
less frequently peitoiated than the bionchi
At tot perforation the softened contents of the
glandb mav be dischai^ed, and the poitor.tt ion
closed b\ ru.tti i^alion, the seal left being small
and not tending to < ause stenosis of the tube as
in cicatusation of sxphihtic lesions \\heu pel
foiation oecuis thoio is a liability to the oceui
lence of luLinoiihago fiom eiosion of vessels, but
this is laiely so sexore .is in the cases \\heie
the lung itself is imolved Fatal asphxxia ma)
follow the impa<tion in the glottis of a laige
caseous mass in pioiess of disihaige Modias-
tmal abscess \vith suimoal emphxscma followed
pel foiation HI one case of the wiitei's, lopoitcd
in the J^nttttnnin, June lS9"i
(n ) I'lcssiiio on the limy itsolt lesults in
intiammatoiN adhc'sions, .ind in this x\ax the
lung lissiu hocol ncs uuohid, and mliltiati d
\\ith c.isc'oiis nutciial \\huh tends to soften and
f oim (axitics These aie not uncommon in the
lowei lobes ot the luni» Malignant disease of
the bionchi.il ulands usu.illv extends m\\aids
along the hionchi, eompiessing them, and
fiequentlx pioducinua bionchiec tatic condition
of the limu
(ni ) The eflects of piessine on the blood-
xossels show themselves c'lneilv on the \eius ot
the head and neck, \shuh become ox ei -filled,
and these paits become congested and oxen
wdenifitous The smallei \ouis mav ha\o then
walk invaded b\ tubeic'le, and thus bc»tome the
means ot pioclucinu a geneialised tuben ulosis
Kiosion ot blanches ot the pnlmon.ux aiter\
and \em in the lung may gixc rise to piofuso
and even fatal luemonhage The artenes are
much less commonU affected, though cases aie
on i coord whcic a eietaceous gland h.is ulcciated
into the ,iojta and pi od need fat.il htomorihago
(iv ) The oftocts ot piessure on the neives in
the case of caseous bronchial glands aie veiy
difficult to distinguish horn those due to pios-
surc on the an -passages themselxes, but theie
are, at the same time1, cases where piessure on
the recurient laiyngeal neive of one Hide has
produced inulatei.il paralysis of the >oeal corda
Tho vomiting xvhuh ocruis in association \\ith
enlarged glands, <is x\ell as in some cases ot
pulmonaiy tuberculosis, has been attributed by
some to the effects of pressure on the branches
of tho vagus nerve Malignant growths in the
I bronchial glands may, howoxei, produce marked
i prc&Huic eftects on the neiven (*>/c/r " Medui-
1 stinum ")
(\ ) The ott*vts of pressure on the a?sophagus
ate evidenced bv some nai rowing of that tube
and (onsecjiient dxsphagia Adhc'sions ma)
ionn between the glands and the (rsophagus,
and if cic.itiisation oecuis the wall ol the
a soph. iu; us may lu diaggul on, and thus a
fraction <li\eituulum result J'eiioiation of
1 the d'sopha^us b\ a caseous gland is not of xeit\
laic ominciiLo in clnldien , in examining the
locnids "t »>^ei .JOOO c ises in childien thoir
\\eie fhiitoen such cases 01 about 0 4 pel cent
J\i toi.ition of the usophagus may be accom
1 pained b\ ]>iotusc and evt-n fatal luemoiilmgo
Win 11 nipt-ne into the an -passages o( ems at the
same urn.-, '.{align nous pioc esses aie luble to be
set up in the lungi 01 me<liastmum
! (M ) Prc'ssun on the JHHKII <(niw mat\ cause
adhesion between the peix.iidiai H.K <md the
glands, and peitoiation into the pciicaidial sac
mav iollou, and then a tubcmilous 01 suppura-
1 tixe pen i aiditis mav be set up Peifoiatum of
the peiuaidium takes place, most commonly in
the uppei pait ot the scums sac
In addition to these ex cuts we ma} find a
combination of two 01 moie of the aboxe-
mcntioned conditions OK lining simultaneously
Tho wntei Ins seen a cast- wheie caseous
biondual tr lands had peitoiated the <is(>phagUH,
n trlii bionchus, luzhtlung, and the peiu.udium
iS'iw/'/fiws 4\/» /'//isff n .S'/f,vs — Enlaiged
biondual glands max cvist xuthout gixing use
to am sxm|)toms, and toplixsical siujns of xeiy
little diagnostic \aluc1
The c hiet s\mptoms picxiuc<>d b\ them aie
couah, \omitiny, d^pua'o, chsphagi.i, and pain
Cou</h This is paio\>.smal in chai.u ter, and
c loselx losembles that of xx hoopm«>-cough Asa
uile it is unaccompanied by any expectoration
01 whoop, but when sexeie max be accompanied
bx xomitnui
\\hen the tiachca 01 bionchi aie being m-
\aded b\ i.iseous glands then1 is usually some
i tiacheitis and luonchitis, and this IN not m-
fiecnic'iitly a' coni])anied bx heemoptvsis \«irving
j in amount finin a meie stieak of blood to piofuse
' 01 ex en fatal luunun i hai«e
i In some cases the cough has a distinctly
I clanging chaiactei The xoice, as a inle, is not
; altoiod, but sometimes the ciy has a distinct
I studoi The paioxxsms ot (oughmgaro some-
times so sox ore that aitei them the child will
fill back quite exhausted Kpibtaxis max
I accompaii} a tit ot coughing, but much less
commonly than cxanosis When a caseoiiH 01
< ciotaceous mass ulcoiatcs through the an-
passagc's, in addition to the lucmoptysw men-
tioned, the caseous or eietaceous mass maybe
oxpectoiated
Yonutnig M pie&ent in some CMSOS, and genei-
all) accomp<imcs severe attacks ot coughing
10
BRONCHI, DISEASES OF— BRONCHIAL (1LAND8
When the oesophagus is imolved theie may
be heeiiiatemeHis, and the passage oi blood in
the stools , 01 if the an-p«is8ages are involved
at the same time, food may be expoctoiated
The )>reath m a large number of cases oi
ulceiation into the* an -passages has a very
offensive smell, though fojtoi oi the breath
does not necessaiily indicate ukoi.ition into tlu>
(vsophagus
Dyspnea is sometimes well marked, tho
patient being unable to lie do\ui in bed, and
dreading any movement 01 intoifcioine such as
for feeding 01 c hanging •
The dyspncra in ^ome discs is moie «)l the
i Kit in c ot an expnatoiv than aii inspnatoiv
dyspnoja
When the i win i out l.tiyngeal neivc is in-
volved b\ a ue\v growth 111 the biouchial glands
the vocal coidb mav bo paialjsed (unit " Medi-
astinum ")
Dy*[>}ui<n<t mav be associated eithoi with
pressure ol enlarged glands on the u?sophanus,
01 with actual ulceration of a caseous inland
through tlic ci'sophageal wall It is not a voiy
(ommon svmplom
i'tun \viien piesont is generally icieiied to
the legion of the mamibiium, oi less coinmonh
to the cpigastiium When the asophagus is
involved then- may be soim pain in swallowing,
although extensive iikei.ition of that tube may
be pi esent \\ithout giving use to am symptoms
T/if jifit/*trn/ wf/wv piodueod by enlarged
bronchial glands aie oi ton marked b\ the sign^
of othei concurrent dise.ise in the chest
fuijieition The faee is frequently cvanosod,
especially aftei an att.uk ot couching, and
there is often m.nked d\spnuia with recession
of the lower pait of the thorax this recession
is, as a mle, bilateral in small ehildien, but in
older (hildten in \\lioiu the thoracic parietes
aze hrmei theie mav be distinct umlatcial
if cession The lower pait ot the btorimm is
often letracted dining inspnation The veins
over the fiont of the (host aie fiei|iientl\
enlarged A model ate ainount of d'dem.i or
the face may be picscnt
JWjxitton, in addition to lonfiiming the
icsults of inspection, mav icvt'al tho piebcnce of
enlarged glands in the neck 01 .ixilUc The
]>iesence ot surgical oniphvsenu mav .ilso ln»
verified Vocal fremitus, or m small ehildien
the cty fiemitus, ma\ be diminished over the
area suppbeil by a c'ompiessed broiu bus, 01
mcie.ised ovei the mamibiium
/V/r?/ss«o/i — Impairment ot leson.micot the
pel cushion note m.iy be piescnt <i\ei the
manubtium and innei end of the fust 01
second intcic>ost<il sp.ices antenoily, and simi-
larly m the supiascapulai fossa; .ind intc-r-
scapular region posteiiorlv The peitussiou of
the back is mutlt less tellable m small childten
than in adults Special caie should be taken
in examining small ehildien to <>cc that the
child sits up or is placed quite straight, and
not allowed to he over to one side, <ib it is
so apt to do when being held by the mother or
muse
Auxcuttatton — The bieath sounds <>\ci the
lungs may be simply weak, while ovei the dull
aiea there is often maiked tubulai 01 bionchial
bieathing, and in some cases theie may IK«
almost amphoric bieathing Vocal lesonance
ovei the dull aiea is inci eased, and mav have
.111 ojgophonu chaia<tci When cataiih ot the
an -passages exists theie aie tin4 usual signs of
this condition, and should these be unilatcial in
distribution, suspicion should be directed to the
hioiulnal glands The usual sequence ot aus
cultatoiv signs in the lungs is \\cak bieathing
followed bv bionchial bieathing, to which hue
c tackling raits, and eventuallv sonoious and
bubbliim sounds, aie added
Wheie the lunu is involved eithci in tubei
culous processes or bv the foil natron ol hic.ikiug-
dovMi areas, thesi signs become masked bv those
ot puhnon.iiy tubi ic ulosis, 01 un})\eni.i, oi the
siuns of bionchiectasis
Eustace Smith has pointed out that i pun urn
sound (an be prodmcd in the vessels ot (he neck
dm ing icspnation bv miking tlu child look
upwaids, and so extend the neck and compie^s.
the vessels bv the lef lo-manuhiial ulands The*
stethoscope must be applied below the Mipia
sternal notch
If srgns ol tuberculous consolidation aie
present and aie limited to the middle lobe, this
vxnuld suggest the hioiuhial glands as the 'o//s
et oiufo imilt
I)nt,Mt^i^ — It must be home in iiiiud that
the (ondition iieijuently exists without uivrng
use to any symptoms, and fuithei, tint the
physical signs are often equivocal Evei\ con-
dition liable1 to produce paioxvsmal cough and
dvspncL'a must be ditteiontiated Ol these the
mote nnj)Oitant aie whoo])ing cout;h, c'lilaigc^l
tonsils, pulmonaiy tubeiculosis, empvema, .tivl
broiu hiectasis
In other cases asthma, a toieit>n liodv m the
ail-passages, adhcicnt ])leuia, piessuie on the
an - passages by aneuiysms, abs«(»ss, a new
giovvth, pieveitehial abscess in the uppei doisal
lemon, laivngeal diphtheiia, «uid laiyngisiuus
studulus must be excluded C'aietul cimsideia-
tion ot the history and detailed examination oi
the phai vnx, larynx, and chest will usualh sufhce
to differentiate these conditions
/'/••ofrws/s -When the enl.ugement is duo to
malignant disease this is ncccssanly hopeless,
but when due to tubeiculous disease it is not ot
necessity so giave, and yet it must be home m
mind that tubeiculous meningitis not intic-
quentlv is met with in cases m which the
bionchial glands ate the only recognisable sites
ot previous tubeiculous infection Hecoveiy is
possible even when the air - passages 01 the
crsophagus are peiforatod
BRONCHI, DISEASES OF— BRONCHIAL GLANDS
11
TRRATMhKi — The treatment of enlaiged '
bioiichial glandn is that of the diseases which <
cause the enlaigement
Prophylactic treatment is of great impoit-
ance Aftei an attack of measles, whooping-
cough, or mfluen/a, when all nsk of mtection is
past, a stay at the seaside, in a pait having a
shelteied and son the in aspect, is advisable, 01
else in some high and diy locality sheltered
irom the east wind Chi) soils aie to be
avoided The clothing should be waim, woollen •
undeidothing being best, and the limbs should
be entiicly coveicel uy> It is astonishing how
much thoughtlessness is displa\cd in the c x-
posuie ot the lowe'i limbs oi chilchen to the .in
out ot doois, both in health and .liter illness, in
the etioneous hehet th.it it is "stiengthemng'
to them '
Special pi (cautions should be taken with the
iood, all milk being boiled, unless the absence
of tubciiuloiis disease in the cows has heen
ascei tamed by moc illation
The dwelling and sleeping looms should be
laige, light, well ventilated, fiee horn dust, ind
the windows should be kept open at night
The' medie mal tieatment of these' c asc s consists
in the admnnstiation of some toim oi <od IIVCM
oil in combination with non, 01 mal tine, 01 the
hypophosplntc s
The sMiip oi the1 iodide ot 11 on, in doses of
0 10 minims thie'e tune's a da\, often pioduccs
maiked diminution of enlai^cd ulands m the
ni'ck, and has pio\ed useful m case's when-
the biondnal ul.inds weie also enlarged Sul-
phide of e.deium his been iccommc'iidcd m
doses of one'-t \\entieth to one-tenth of a giam
e\eiv houi Aise'iuc m iv be give n m combina-
tion with non, 01 with a vegetable bitlei
Iodine in the ioim ot the t me tine, in doses oi
one to tlnec minims, may be tiled
Foi the tieatme'iit ot the' cough and vomiting
the vvriti'i advocates the employ ment of the*
glyceiine of caibohc acid, in doses of one- to
thiee minims, m combination with cod hvei oil
and non Cicasote in capsules is also useful
if complications aiise, i- <f tiiheic ulosis ot the
air-passagcis, e losionot the ersophagus, cnip)cma,
etc , they should be tieated along the line's nidi
eated undei these headings
Tiae he'otomy is onlv of use when a case-oils
mass is nnpac ted in thc> ti.ic hcu 01 glottis
Bronchitis
DBIIMIION
JNTRODUI FOKY KhM\KKs
I Ac'UlK IJR()\( Hills [\ \|)L1 is
Mottnd A no to fti
Symptom s
CornjJ nations
Treatment
11
11
U
1()
16
18
18
II CHRONIC BUOM unis i\ Anuns
Etiology
Mm tivl A natomy
tiymptnint
Cornel tuitions
CLINK AI Vviiiiiiii«s
tinnulun ihwa
Cntnnhf <SVr
19
1 9
19
20
20
20
20
III BltONCllillS IN riUIDHbN J.)
KsANin 01 ClANOSIS JO
Xt< <l/<fi \JCr)H()l (CllMfit/ lj \ft) , AM 01101 ISA!
((1viHjt/fr<ttntn\) , VN LSIJIKJK s, KiifKii , ASJIIMA,
PmoM'FII, Bl{()\(III\L (Jl \NDs , liKONCHf,
HiioscniK IASIS HLUNS \ND S< \i i»s (Chunal
/'Vw/Wf, Ih^nnitnii/ Comji/ tint ions) , (1HBs'i,
ClIMf\l lN\liMI(.\llO\ OI ClIIllHiFV, I)K-
\HOI'M1AI OI (titJIHJttoi/l>* of J\tf/H)K/) , CofCiH
(Chmtitl Vnmtit*) KXPFMOKMION , <!oi p
( fa yiu atnty Xys/oi/) , Hh\Ki, Ah oc \KDII M VM>
KNIMM \uiiiiM (Xi/injttnnni1nl<Hiii) II 1 Moi'l \s|s ,
Ll'Mi, Tl IIMMLinM* oi, itc Ml- \M?S, \H'H-
KJll^ <)\M,hN , I'M I M<>M \, ClIMl'M, , I'HK.-
N \S< \, Vl I hi HUNS AMlCoMIM K VIldNs, Ul( Khl^.
SMVMI-OV, TiiiiiM'Li IK s, Hi \IIK Kfcs(»His
TH \HI-s, D\N<,HJOls (('ulfoil), TlHFlif LLOSIS
hiioN< mi is is in inflammation of the bionihial
tubes, geneial 01 paitial, nnohmg eithei the
l.uaei 01 smaller hi one hial tubes
The teim hiomhitis is oi «)in])ai,iti\el\
lecent d.ite, h.iMiig heen mtuxluced b> Di
Chillies Kulhain in 1810, when it sujxiseded
th< old phiase " pulmonan < atari h or "de-
Dux ion
Foi the puipose of desmption the subject
\\ill be divided into the following sections —
1 Uute bionchitis in the adult, 2 Chronic
bioiu hitis in the adult .) Bronchitis in ( hildien
(r'fHcxif (\ni\u?emtio)t* — It w oiild n.ituiall)
be supposed that the bionelnal t vibes, lamit^mg
thioughout the whole of the lungs as they do,
should be so mtiinsically a pait of the lung1 that
no iluneal dmsion lould be diawn between in
fl.irnm.ition ot the bionchi and inflammation ot
the pulmonai\ tissut , ])neumonia And though
tiom .1 clmieal as well as fiom a ])athological
standyKHnt hiomhitis is shaiph differentiated
fiom ])ii(>umoni.i so long as the largei and
middle -H/ed tubes ate alone affected, we shall
seek in vain tot «un line of dema nation between
capill.irv bioiulntis .ind the lobular pneumonia
with whidi, in children at anv late, it is almost
mvaiiabh associ.ited
To appreciate the fiathologual changes taking
plate m bronchitis it- 1S neeessaiy to beai in
mind the noimal stuutuie and functionb of the
tissues imolvcd An explanation will be found
foi the tendency foi the inflammation to be
12
BRONCHI, DISEASES OF— BRONCHITIS
mainly bronchial, fiibtly in the anatomical
arrangement of the blood-supply, and secondly
111 the protecting action of the basement mem-
brane, while even the marked vaiiation in the
clinical characters between bronchitis affecting
the largei and smaller tubes veij hugely depends
on their different anatomical struetuic and rela-
tions The note* oi thy point m icgaid to the
vascular system of the lung consists in its
double en dilation, the blood-supply toi nutn-
tion and function being sepaiatclv pro\ided foi ,
thus the main bronchi and the tissues of the
lung are supplied, not by the pulmpnarv aiteiy,
but by the bronchial aiteiies which .ue demed
from the aoitri Fuitheimoie, the bionchial
veins communicate iieely with the pulmonary
arteiy, and in the smallei bionchi the blood is
letuinetl almost wholly by blanches of the
pulmonary vein to the left side of the hcait,
consequently any olmti notion to the letuin oi
blood to the left side of the heait will at once
Jesuit in congestion ot the tmal/n bronchi
Moico\ei, while it seems probable that the
pulmonaty aiteiies are not subject like most
arteries to \asomotoi contiol, this does not
apply to the bnmchial aiteiies, and thus a
\anety of causes acting eithei dnecth, 01 m-
duectly by leflex action, aie able to cause a
vasculai dilatation which ma\ be limited to the
bronchial tubes, as distinguished fiom the an-
vesicles which ate sii])phed bv the capillaiy
plevus of the pulmcmaiy vessels, and which aie
directly eonceined with the function oi lespna
tion — aeration of the bloexl
The right and leit hionchi di\ide and sub
divide dw hotomouah \\ithm the lung until
ultimately the minute tcimuml biondnoles end
in the infuiidibula and an -\esicles In a tians-
verse section of one of the middle-sued hionchi
three coats may be distinguished — the mnei
mucosa, the middle muscular is, and the outci
hbrous coat, which contains the caitilages
Furthei examination shows that the mucosa is
composed of (1) an epithelial lining with three
layeis of cells — the single layei ot supeiiieial
columnar ciliated epithelium, an intermediary
layer of transitional 01 lounded cells, actively
germinating to toim the supeituial columuai
cells and mucous corpuscles, and a single deep
layer of flat nucleated cells , (2) an inner hbious
coat, abundant!} supplied with branches horn
the bronchial aiteiy, and consisting of bundles
ot fibrous tissue with numerous lymphatic spaces
containing lymphatic corpuscles between them ,
and (3) a homogeneous, hyaline, structineless
basement membrane gmng attachment to the
epithelial covenng which it effectually separates
fiom the vessels and hmphatic vessels of the
mnei hbrous coat Hamilton has shown that
the part played by this basement membrane in
bronchitis is of gieat nnjKutance, in that it
imparts a superficial character to the catarrhal
affections of the bionchi , for though it becomes
swollen and uxlematous in bi on chit is, and per-
mits the tiansudatioii of serous fluid into the
lumen of the tube, no leucocytes appear to pass
horn the deepei structures to the surface ot the
mucous membrane, nor can inhaled particles of
ioicign mattet, like (oal-dust in a miner's lung,
become carried down to the tissues of the
bionchi Such particles do not entei the
lymphatics of the lung evcept thiough the aii-
\esrcleM In the middle -sixed and smallei
bionchi the muscular < oat is well de\ eloped, and
it is continued down to the infuiidibula, wlicie
it is icpiesented onlv bv a few scatteied fibres
The pltysiologu.il action oi this muscle' is not
known evactU, but it piobably legulates the
mtia-aheolai an - tension, and piotects the
.m - \csitlcs from undue piesMiic in coughing
.ind othei lespnaton acts Consccpientl.v, .is
Hamilton h«is demonstrated, this coat generally
becomes greatl} h} pel tr opined in chiomc bion
clntis, owing to the constantly iccuiimg cough
(Uandiiei, m discussing the action oi expec-
toiant medicines, amves at the conclusion that
evpectoiation depends mine upon the expulsive
mechanism ot these muscular fibres than upon
the alterations in the c (insistent \ ot the secic-
tions Then .ic tion is probably somewhat
analogous to intestinal pei istalsis, and the
henehcial tesiilt oi emesis in <ertam cases oi
bronchitis is due to the remedies increasing the
act ion oi the bronchial muscle's dnecth, i.ithci
than to the \omitnm, which is pel haps onh a
concomitant, but in no w iv essential, elfect
Fuithei evidence ol this impoi taut ph \srologieal
action is attoided bv the tut that, when the
mnseul.ii coat loses its functional activiU, as in
the moie senous caws oi bionchitis, the bion-
chial tubes dilate ami become hi led with secu-
tion Walshe, letemng to Hadchile Hall's
leseaiches, tonsideis that in the calm, and still
moie in the forced respiration ot health, the
niusc'iilai coat jrossesses the powc*i of reducing
the tubes to less than then medium size But
in bionchitis the muscular coat loses it s< on trac-
tile toice, the elasticity ot the inflamed bronchi
l>eing likewise* impaired, and so become intel-
ligible the tendency to dilatation of the tubes,
the labouied expnation and the accumulation of
mucus
It is not improbable that, like the al.c nasi
and \ocal coicls, the bronchial muscle m.i}
rhythmically dilate and contract with inspira-
ticni and c-xpn.ition I behove that this largeh
explains win m bronchitis and asthma the
d\spnciM is expnatory lathct than mspiiatoix,
inasmuch as the muscular spasm is moie 01 less
inhibited duimg inspiiation, jx'imittiug air to be
inspiied moie fieely than dm ing the period ot
bronchial spasm it can be expired, consequenth
the lungs become distended and cmphysematous
In the laigei and middle-sized bionchi the outei
hbrous coat contains cartilaginous plates, but
not in the smallest bionchi, which consist of a
BRONCHI, DISEASES OF— BRONCHITIS
13
layei of stiatincd ciliated epithelium, surrounded
by the muse ula us and peribionchial connective
tissue If one of the biomhioles be followed
towards its tci initiation, it is found that just
befoie it ends m the mfundihulum the eolunmai
ciliated epithelium is leplaccd b\ a single layer
of < ubicvil e])ithehurn, a thin tihions tissue m-
\estment being still piesent, and finally AN hen
the .in -vesicle is leadied this epitheli.il la\ei
eoiues to be composed ot a \eiy thin lavei of
flat, sijuainoiis, endolhelial-like cells, \\hile tin
museulai U).i1 is lost
The thinness <ind weakness ot tin walls ot tin1
smallest burnt hi, and the feeble expulsne po\\ci
of then niusdilai coat, toucthci with the nan o\\-
ness ot the lumen of the tube, and e'spee lalh the
complete absence of uhatid epithelium, .ind oi
any musuilai coat .is they appioaih the 111-
iundihula, explain the seiious natiite ol a < apil-
lai\ bronchitis and tin* danirei icsultmu tnuii
seeietions ace umiil,itini> in the smallest tubes
1 A< I IL UlloNC Jlllls IN VlM I I"
Kaolin,} — \N c m.i) di\ide the cause-* oi ai ute
btonchitis as iollo\\s
(a) 7'jffY/i/f-KifMf/ -No aye is exempt, but it is
espeeialh liable to .itt.uk the \ci\ old 01 the
voiy young, and to assume a seiious hum in
these subjects Miles ind temales aie cquallv
liable to suflei Sc'dentai \ lite and luMiiious
habits, and huiwr niiuli mdoois and in \itiated
atmos])he]e, hc.iit-dise.is>*, especially those hums
which icsult in pulmonary congestion, uid gout,
diabetes, lukets, dvspepsia and constipation,
spinal eurxatmc, dusty occupations, .m<{ ,i cold
and chaimeable climate, all piedisposu to bioii-
chitis hut heredity and a c CM tain mdiMclual
susceptibility to cataiihal ailections undoubtedly
laigely influence the' occimcmc ot attacks, and,
aboM1 all, the pie-existence of vanous pulmonaiy
affections and the fact of ])ie\ioiis attacks ot
hionchitis h.uing taken place
(k) Eitcitinti cauw
1 Exposuie to cold , "catching i old "
2 Traumatic , the inhalation of steam
swallowing hot water 01 nutating fluids
3 Chemical nritants, e </ the* inhalation ot
irritating gases or vaponiN such .is chloune 01
ammonia, sulphuious en nitious acid, ethei,
iodine, bromine, etc
4 Tovenna, e <j in Blight's disease, gout,
iheurnatism
5 Vasomotoi, e r/ asthma
6 Infective, e ij typhoid, typhus, measlos,
scarlatina, smallpox, malaiia, \vhooping-cough
Acute bronchitis is geneially associated \\ith
exposure to cold, and it is eeitamly influenced
by climatic conditions But .ilthough a so-
culled chill is undoubtedly a veiy common
exciting cause of bronchitis, it is equally certain
that in many cases the real cause of the attack
is by no means so simple Indeed \ve hud that
it is not those whose daily life constantly exposes
them to cold, or even i.ipid changes of tempera-
ture, that aie most pione to attaeks ot bion-
c hitis " persons who h\e an out-of-door life aie
usually less subject to the disease than those
who follow sedentaiy occupation" (Osier)
('CM tain it is th.it colds aie not usually caught
in pine an, at sea toi instance1, or in the highei
Alps in wmtei, although e\j>osuic to cold is of
necessity ficejuent vcutc mlfammatoi\ attacks
oi the uppci an passages aie most ficquentlv
iound in those who habitually buathe vitiated
an, oi who ha\e attendi'd o\ei -c lowdcd, ill-
vcntilatcMl [>J,ues of meeting, and aie then
eix posed to e old, 01 who are1 dnuth infected by
some pe • -.on snffi ring tioin a cold in the head
Not onl\ do these "catanhs ' eonfei temjioraiy
mimuniU, but leccnt unc-st m.it ions, such .is
those of V\ }| I'aik, ha\c» shown that stapln-
lococci and stieptococci, which aie alwa>s
[•resent in the he althv mouth, increase gieatlx
in nunibei and \nuleiue in damp \\eathei and
in wmtcM months and aie then capable of
setting uj) ai ute phaivngitis it ap})bed to the
thni.it These aie ]u-t the conditions which
aie paitie ulaih pione to lead to bi one hit is, and
we- thus seem to h,i\c in explanition of its
ficMjuent (Htuneiue in the changeable weather
oi eaih spiiny, and late autumn, and of its
oiigm m .1 'cold on the1 chest '
Sputum noimalh cont.ims ,i eonsideiablc>
numbei oi difleient \.uieties of nncio oigun-
isms, some1 oi whuh aie best studied on stained
films, whilst otlii'is glow well on the oidinan
no'dia Amongst the most common of these
oigamsms are the stK'ptococcus bie\is and
othcM \ane'ties, sta|)h\l«)cocc us albus, citieus,
an<l auieus, spn ilium sputu^cMium, leptothm,
.mil \aneties oi chiomogeinc baetena, bacilli
and saienue \\hilst any one ot these may be
found in the sputa ot bionehitis and bioncho-
pucuiuoma, it will commonly be found that one
01 moie 01 ^anisins aie piesent in ovei whelming
majoiity, so that piepaied films 01 cultures may
show almost a putc cultuie of one paiticulai
v.uietv Pansmi iound in not null air-passages
sexeial elincMent sti e^tococ-Li, bacilli, muiococci
saicm.e Queyi.it describes a specific oigamsm,
a imciococcus oi " tiachco-bioiiehitis " (»run
desenlH'N a specific bacillus of bionehitis, but
ncithei ot these obsei Nations has been substitn
tiatc'd NettcM gi\e>s the* pneumococeus as the
cause of capill.11^ bionehitis and bi oncho- pneu-
monia in IT) 85 pel cent ot eases
Oslei makes the statement that acute bron-
chitis is probably a nnciobic aflcction, and Gee,
in lefemng to the effect of dust m certain
occupations in causing bronchitis, states that
the dust of unclean ancl ill- ventilated rooms Mill
be veiy likely to contain moibifu mieiobes, and
that the irritation of the an-pissage's set up by
inanimated dust will favour the operations of the
many bacteria which are potent to cause bron-
chitis He believes that oui mouths, noses, and
u
r.liONY'HI, IHSKASKS ( >K — HK< >N< .'II ITIS
throats harbour niiiny morbitie microbes in a
latent stilt c, there awaiting a favourable oppor-
tunity for becoming active and virulent, ami
thus 'setting Up tin.- Ciilarrhal attack which
spreads down to the trachea and bronchi.
Xo doul)l many of the CU.M-S of tracheo bron
eliitis originate in this manner; vet, notwith-
standing the bacteriological researches which
have been just mentioned, I am convinced that
in a larger proportion of the eases of bronchitis
in which the iniddlo-si/.eel bronchi are mainh
implicated from the outset, exposure to cold is
itself the immediate cause of the* disease. It
may he brought about directly by cold air
entering through the upper air passages, as
shown, for instance, by the experience of sits
ccptible persons on going from a heated atino
sphere into cold night air, by the liability to
bronchitis in traeheotomised patients, or in
habitual mouth breathers owing to the inspired
air not beinu' duly warmed bv passing through
the nose. r.ut in most cases it seems that the
action of cold is indirect, and the result of
vasomotor paralysis, as explained by Rosenthal;
for often enough the cause of the attack has
been getting wet, or lying on damp ^rass, or
sitting still after getting over-heated and per
spiring, and not by the action of cold air enter-
ing through the mouth.
Other deep -seated viscera having no air-
containing tubes of communication to the
surface of the body, such as the bladder and
kidney, are similarly and specially subject to
inflammatory attacks from exposure to wet and
cold applied' to other parts of the body ; and in
applying hot fomentations or poultices to the
chest, to the hypogastrium or lumbar regions in
inflammations affecting respectively the lungs,
bladder, or kidneys, we take advantage of these
associated rellev vasomotor areas.
We may further refer to the secondary bron-
chitis \vhich is liable to arise in the course
of intlnen/a, typhoid fever, measles, and other
exanthemata. It is widely recognised that the
bronchitis of inlluen/a, which is certainly mi-
erobial, is especially liable to be aggravated by
the least exposure to cold, while the pulmonary
complications of measles are particularly prone
to be severe if the rooms are at all crowded or
ill ventilated. It is a remarkable fact that
intluen/.a epidemics are just as piwalcnt at
Davos and St. Morit/. as in the less dry atmo-
sphere of Knglaiid and Scotland, and that:, despite
the ideal climate of the higher Alps for most
bronchi! ic affections, cases of intluen/a at these
Swiss resorts are (list as prone to be com
plicated with severe bronchitis and pneumonia.
Thus a chill, while undoubtedly capable of
directly causing acute bronchitis in those un-
accustomed to exposure, or in those who seem
to have a special liability to eatarrhal affections
of the respiratory tract, is often an indirect
rather than a direct influence in causing the
disea.se, and there are the other causes of
bronchitis which can in no way be associated
with either cold or micro-organisms, as the
inhalation of irritant vapours such as strong
ammonia, chlorine gas, etc.
.I/o/:/;//; J.Y.r/<M/r. The morbid changes
underlying bronchitis in its various forms are
primarily an exaggeration of the normal physio-
logical processes taking place in a, healthy lung,
and we shall find that inflammation of the
bronchial tubes is essentially similar to in-
flammation in other mucous membranes, with
certain modifications due to their peculiar ana
tornical structure and relations, so that the
course of the disease, and the. particular clinical
type it assumes in different cases, vary not only
with the actual cause or the acuten'ess of the
attack, but depend in a large measure on the
calibre of the bronchial tubes most concerned.
It is not very often that we are afforded an
opportunity of examining post-mortem the actual
conditions presented by any but the directly
fatal and therefore most severe forms of bron
eliitis. Socoleff, who induced bronchitis in
animals by the application of chemical irritants,
and Hamilton, from post-mortem observations
on patients dying with bronchitis, have in-
vestigated the histological changes which occur
in the bronchi in health and disease, and I am
mainly indebted to the writings of the latter for
the following description of the morbid anatomy
of bronchitis.
The initial change is hypenenna, followed by
swelling of the mucous membrane and exces-
sive secretion. The hypeneruia, as liiermcr
demonstrated, may first atfect either the super
iicial or deeper structures, or both.
According to Hamilton, the earliest departure
from the normal condition is a, relaxation and dis-
tension of the attendant plexus of blood-vessels
KRONCHJ, DISEASES OF—BRONCHITIS
^unifying 111 the inner hhious coat, immediately
licnuath the basement mcmbiane — that is to
say, of the blanches of the bionchial aitciy
In a few hour* the basement membiane became
swollen from scions infiltration Next, and
quite eaily in the com so of the affection, Socolcfl
and Hamilton iound that the ( ihated epithelial
layei desquamates, and is not regcneiated till
lecovei) takes place, when it is iriadually ic-
produced The tells ol this lam undeigo fattv
degeneiation, and Hamilton sa\s that it is no
doubt paitlx destio(\ed b\ this means and
paitly expee toiated, while otheis may be inhaled
into the smallei bionelu, \\ IK ic the} m.iv be seen
l)ing in laige detached masses among the othei
cataiihal |)iodii<ts Wilson Ko\ and Ilicimci
consider that the epithelial desquamation is
l.ugcl\ a post mmteiii e hangc, and Hamilton
admits that the shedding IN seldom complete,
the deep la)ei ot tiansitional cells, 01 at least
the single lavei of fl.it gcimmating tells, usiialh
i em, lining, and b\ a pioee-ss of fissipaious
dmsion i.i])idl\ ic'piodutes the nucleated cells,
which, being contmiialh thio\vn of), give to the
secretion its pet uhai catanhal thaiactc'i At
the same tune the mucous glands aie partie ulaih
active, and it is the combination of this eataiihal
mucus with thi« epithelial cells which gives list
to the so-called muto-pmulent fluid which
OL< upies the bionehial lumen until iemo\ed b\
cxpectoiation \ftei .ibout the tenth da\,
Hamilton lound th.it the congestion not onl)
affects the mnt'i (ibi oust oat, but th.it all paits
of the hionchus exhibit \essuls o\ei distended
and engoigeel with blood, and that, /mn /xw*n
\\ith the c hanges in the epithelial coxtimg, the
mnei tihious < oat becomes mfiltiated with cells
demed from the cndothehum lining the
lymphatic spaces, until the \\hole oi the lymph-
spaces )>ec'ome choked bv these* ne\\ eellulai
products These tolls, atctndmp. to Hamilton,
nevei extend to\\«ucls the hee sin lace of the
mucous membiane, the basement membiane
forminu an impassable barnei in that diiettion,
but the\ m\aiiabl\ spread outwards, tluough
the mtei-uiusculai lymphatic spaces, to the1
adventitia, wheie similar changes will be found
to have taken place Jiut this piobfeiation,
with the piochiftiun of leucocytes, soon spieads
thioughout the lobulai septa to the dee pel
layers of the pleui.i, the whole of the lymphatic
\C8sels becoming the subject of a catarih, while
the lymphatic glands at the loot of the lunj> aie
then invaiiabU found enlaigcd
The hypciccima of the mueous membiane may
almost entnel) disappeai aftei death, but as a
lule it is Lm<rht led, ot m cases of lonj;ei
duration d:uk puiple, and piesents a thickened,
opaque, and velvety appeal ance, the lumen of the
smaller tubes being dunlins-heel by these changes,
and filled with thick, opaque, yellow secretion
which exudes fioni the small bronchi fioni the
cut surface of the lung on piessme. Bronchitis
of the* smallei tubes is accompanied bj pul-
monary congestion and u-dema, and geneiallv
,u can of collapsed lung oi toci of lobular pneu-
monia may be found
Again, Hamilton has found that the hist in-
dication of ieco\eiy taking place in bionchitis
seems to be- the diminution of the congestion of
the mucous membiane, the vc/wsels apparent!)
iccov cimu; their tone, the piohfciation of the
epithelium becoming less active, the cells being
once- rnoie iulh dexeloix-d into columnar cells,
while the eellulai initiation of the bronchial
wall and the 1/mphatu \c>ssels bee omes giadually
absoilM'd in case's which proceed to lecoun)
In those* eases which, fiom the seventy of the
att.uk, oi fiom tailuic of the factors which
make- toi ie«o\ei), 01 which iiuin the outset
o\\m^ to the' petsistc>nce of less acute causes,
pass into the- condition oi chiomc bronchitis,
the mucous membrane and entne bronchial wall
lemain thickened, the must nliu toat becomes
hjpeitie>phit>d, while the mucous glands and
the bionchial taitilages moie oi less completely
disappeai , bem^ i eplac ed by dense cellulai in-
hit i at ion In ad \aiued cases, howcxer, the mus-
(iilans and the ad \entitia become atiophicd
{)iobibl\ owing to the c ellulai inhltiation ot the
>mphatics, and thus anse those changes which
fiom vanou*- causes lesult in bionclnectasis,
emphjsema, mteistitial pneumonia, and othei
]mlmonaiv complications which aie beyond the
scope ot this .11 tide
Col/iijtw nt iln Lnn<i — A collection of the
eataiihal seeietion of bronchitis ma) ternpoiarily
o< elude a smallei bionchus, lesultmg in weak-
ness 01 absence of the vehicular muimui ovei
the conespontlinu poition of the lung On the
patient c oughniir, the occluding mass of sec iction
may be dislodged, the> an again entering the
an-\ess,ols But the inflammation may extend
to the smallest bionchioles, 01 the muco-
puiulent scuction ma) be sucked down so as to
phi« a bionchial channel which itself is un-
affected KspcHialh it in any pait of the lung
sc\eial of these fnu-i divisions aie occluded, no
cftoit ol toughing may suffice to dislodge it
The an m the1 coi responding portion ol the lung
Ihen becomes absoibed by the* sin rounding pul-
nionaiy capillaries, and the an-vesitles collapse,
with moie oi less so-t.illed " compensates \
emphysiMiia ' in the othi'i poition of the lung
Collapsed lung has a pinkish led appcaiancc,
and on section is leddish blown, uiMiig a fiog-
spawn sensation to the touch, and the coiie-
spondmg sin lace ot the- lung is depiessed
Mci eh collapsed lung does not .is a mle become
inflamed, unless it be fiom extension ot in-
flammation fiom .1 neighbouring patch of pneu-
monia, and on the lemoval of the obstiucting
cause, if this be not too long delayed, may
again become inflated But comcidently with
the occuiicnce of collapse, patches of lobulai
pneumonia, with tine led hepatisation, aie
16
BRONCHI, DISEASES OF— BRONCHITIS
usually found, probably due cither to extension '
of the inflammatory process light down to the
air-vesicles and pulmonaiy stroina, or to dncct '
infection by vanous iincio-otganisms (Foi |
fuller details see " Pneumonia ")
•S'iJf/'/uws — Acute bronchitis in its chnual
aspects picscnts evety giadation tiom «i mild
and tiansient cold on the chi'st to .111 intense! v
acute and lapidly tatal disease attended \\ith
uigent dyspnoea, ey.inoMs, <uul collapse In
the mildei toims, 01 ttachco-hionchitis, the*
attack is usualh ushoiod in 1>) the s\mptoms ,
of .in oidinatv ' cold," \\itli «!ac hi \nuition,
snco/ing, and a stiffness and soieness of the j
thioat The <atanh ma\ extend gtadnalh to i
the « hest, m\ol\m<> the lu\n\ with icsultuu;
hoaisoness, and causing a sense of tawness and
soienoss behind the steinum In othet cases
tho cold .seems to settle on the chest t»om the
outset vMthont obuous phai \ n^itis and lai\n-
gitis Initial ngots ate not usual , but a sense ,
of chillmesH, slnvei ings, pains in the bones ind i
back, genoial malaise, headache, diowsinoss, I
and languoT, with more 01 less gastiio (ataiih,
hepatic distui bailees, and constipation, ( ommonlv
ehaiaetenso the caihei stages Tho pulse and !
lespnation aie modetatolv quickened , the skin, j
at first div, soon becomes moist '
In still othei cases, paiticulaih in the old 01
veiy \ounir, the onset ma\ be almost sudden, •
with seveie couuh and undent d \spnuM, as j
Wilson Fox dosmbis it, ,ilni(»st teproducing ,
the phenomena ot spasmodic asthma, but difloi I
ing tiom the lattei in its persistence , 01 tough |
and dyspneiM ma\ sot in acutely, but without !
so distinct .spasmodic element, followed aftei a j
few houis by the expectoi ation ot an abundant, I
glairy, blood-stained mucus
In mildei cabes the tcmperatuie is but slightly
raised , but \uth the mote seveie it mav tango
between 101° F and 102" 01 10T, showing the
usual evening use and the morning dec lino
The mine is of the usual febnle character, ot
high specific giavity, high-coloured, loaded \vith
lithatcs and inea, and ticc fiom albumen unless
complications aie ptcscnt
The cough at fust is haish, loud, and tinging,
either coming in frequently tepeated single
coughs, or in paroxjsms which ate exceedingly
harassing to the patient, accompanied by a
sense of oppression and tightness in the chest
and a considerable soicncss beneath the steinum
and along the attachments ot the diaphragm,
the seveie ]wro\\sms sometimes ending in
\oimting It is often most distics&mg in the
earliest stages bcfoie theie is any cxpcctotation,
being then duo to nutation of the inflamed
bronchial mucous memhiano, tho itntation
being icfeitod to tho latyngo-tiacheal region
Aftei an interval tho cough is attended with
expectoration, whuh at fust is thin and watery,
and fiothy, consisting of serous exudation con-
taining the ciliated epithelium which is shed
very early As the disease progresses, it
becomes moie consistent and ropy, from tho
increased exudation of mucus, and more 01 less
opaque, owing to the numerous lound cells
thio\\n off ft om the deeper epithelial layers,
becoming in tuin muco-purulcnt and puiulent
The* cough is then due, not to nutation of the
div mucosa, but to the accumulating scctctions
which loqiute to be got lid of, and is theiofoio
apt to bo moie scNcie on using horn the teciini-
bonl position aitei sleep Stieaks of blood aio
sometimes seen in the sputum, especialh in the
catlici stages when the coiiuh is seven1
DxspiiUM is seldom pioncmtued when the
lamei tubes done ate affected ^ hen the
snulli'i tubes .no oxtensi\ely implicated, owing
to the excessive contiac tion ot the muse ulai
coat at ting in tlu manncM explained aboxe, and
peih.ips in pait liom the \al\c«-like action ot the
ac c uinulatuii; sedetion, mote1 .111 is cliawn into
the lung than can be* expired, and the lungs
coiisoquentU bc'come o\cr-chst ended and the
iespn.it 01 v movements shallow and incltcctiial
It is icmatkable that, the d^spncia is aUlommal
.ind oxpnatoi\, i.ithei than mspnatoix, in
contiadistinction to the dxspiui'.i dne toohstiiu-
tioii in the laiMix ot ti.uhoa \\ lion the- an-
vc»sicles ate ilioaily flisteudoil with the an uliuh
no elhnt ot the patient < .in ctteitu.dh c-xpnc1, but
little1 01 no more an can entei, and thus thcie is
not mueh tendenc \ foi the- soiiotion to be sucked
in I'Apec toiation is then attnulc'd with much
dimtulU, and the* thick, vollow, stuk\ secic'tion
f i om the small tubes is seen to hang in stimus
suspended in tho lowei \\aron layoi I torn the
uppot lavei oi fiothy mucus fiom the upjK'i
latyer btonchi Sometimes the expectotation
is xciy scantv in capillary bionchitis, even \vhen
moist talc's ate audible o\ei the chest
An attack of acute bronchitis mav assume an
asphvAiatmg t\pe, eithet from a smi]»lo bton-
chitis of the laiget tube's oc cm ring in a
debilitated patient, especially in the emphy-
sematous, or fiom a veiy extensive- implication
ot tho smallei btonchi, ot from widesptoad
involvement of the capillaty bionchi Though
capillary bionthitis in the adult may be remaik
ably sudden ,md &exeic m its onset, it not
infrequently oommemos \\ith tho symptoms of
an ordmaty mild btonchitic attick Rigois aie
laie, says Walsho, and vomiting raiei But
neivoub svmptorns supervene early and are
pronounced, tlie patient is lostless and diousy,
the pulse i.ipicl and small, cyanosis is a marked
i oat me, and thoie is complete loss of appetite
Muttoiing delirium at night and sleeplessness
aie common, but a<ute maniacal excitement is
not unknown Tho acute dyspnoea, cyanosis,
and active, sometimes maniacal, delirium when
stiong, young adults are the subject of acute
capillary bronchitis, form a veiy painful clinical
pittnre If the attack cannot be relieved the
i patient rapidly becomes asphyxiated. Walshe,
BRONCHI, DISEASES OF— BRONCHITIS
17
in his description of this typo of bronchitis,
states that, "as long as the strength permits,
the patient bits or bonds forwards, but the
body gradually yields and it is not uncommon
to find patients, while still perfectly < onscious,
lying sideways or forwards, with the head lower
than the shoulders, and in rare cases this posture
of the head is adopted from the very outset "
Piivw u ,SV,,vs —The chest may not be
altered in shape in mild cases, but m pro-
nounced attacks assumes the mspnatory type ,
it remains more 01 less iulh expanded, the
respiratory nimcmuiils being ele\atory rather
than attended with expansion and contraction
of the parit'tes, and arc \iolent, and mei eased
in frequency, though not in amplitude The
abdominal movements are inci eased, and if the
bronchial tubes are extensively imohod, there
will be marked cyanosis and fulness of the large
\eins of the neck The right side of the htait
dilates, giving rise to epigastric pulsation, 01
the heart may be pushed down, the impulse
being felt in the left cost.il angle The liver is
often congested and displaced downward But
in the acute Asphyxiating type, as has ah cad y
been stated, the respiratory movements of tin
cner-distended chest .ire increasingly shallow,
and the heart's ai_tion is apt to fail lapulh, with
marked cyanosis, elamms perspnation, coldness
of the skin, general anasaica, and scanty all >u
mmous urine
The adventitious sounds which anse in hi on
chitis are of two kinds — the diy (rhombus and
sibilus) and the moist (idles) Hhonchus, 01
sonorous rhouchus, is a loud, deep-toned, cooing
sound, due to an passing through one of the
larger tubes which is partly obstructed bv a
collection of mucus, producing a vnm Jlinde
The1 mucus can often be removed by the1 patient
coughing, hem e ihonchus audible at one moment
may abruptly disappear Sibilant rhomhi, or
sibilus, is a more high-pitched whistling sound,
duo to swelling of the mucosa in the small
bronchi , hence they are of graver importanc e,
and as they cannot be dispelled by toughing,
they tend to persist m the same region foi a
considerable period
A rhythmic ihonchus or sibilus, .is was hist
observed by Stokes, may be produced by the
ventricular contractions, if the portion of lung
is in close proximity to the heart and the
secretions abundant
Rales may be large, medium, or small, accord-
ing to the size oi the bronchial tube which is
occluded by an accumulation of mucus, the
sound being produced by the an passing
through the mucus Moderately fine rales,
however, may be produced in the larger
bronchi Large rales arc of less grave impoit
than the small, in that they imply that the
larger tubes are mainly affected, and mere
loudnesa of the sounds is not of bad omen — m
fact, it is in the graver cases of widespread
VOL II
implication of the finer tubes that the rnoist
sounds are least audible The smaller rales
are sometimes spoken of as sul>-crepitant. Yet
it is of considerable importance that they should
be distinguished from the crepitation which is
indicative of pneumonia or of phthisis, conditions
which may be associated with the symptoms of
simple bronchitis
A plug of mucus in a bronchus may
tcmpoiaiily prevent the air entering the corre-
^ponehng poition of the lung, and causes a
localised diminution or absence of breath-
sounds, until >y coughing the plug is it moved
But usually in bronchitis the amount of air
entering the \esules being deficient, the normal
vesic ulai murmur is less distinct than in health,
consequently the bronchial bi oath -sounds are
less marked and the breathing seems unduly
harsh Yet the bronchial breathing is ne\er
heard in uncomplicated bronchitis, except ovei
the roots of lungs, it is only heard when
eithei collapse 01 pneumonia is present, and
ma^ then be associated with dulness on per-
cussion and increased vocal resonance
Vocal frenntus and voice -conduction are
scarcely altered in uncomplicated bronchitis
The percussion -note is normal unless the
bronchitis is pr onounccHl, and then the whole
of the upper part of the chest, being acutely
distended and cmphx sematous, yields a hyper-
lesonant 01 almost t\mpamtic note Kven
small patches of broncho -pneumonia do not
give use to dulness on percussion, but con-
gestion of the bases, collapse, or pneumonia,
if extensive, causes a diminution of the reso
nunc e The tongue is almost invariably coated,
and symptoms of gastio-intestmal catarrh, with
anoicxia, thirst, and constipation, are generally
present
In uncomplicated cases of the larger and
middle -si/ed tubes the attack gr.idually sub-
sides in the course of a week, the expectoration
iKJcommg decreased in amount and more noimal
in character, the physical signs in the chest
gradually disappearing, convalescence being
established in about ten days or a fortnight
But in the old and feeble, and in young
children, the disease is apt to extend down to
the smaller tube's, with a liability to pulmonary
collapse Especially is this dangerous complica-
tion likely to arise in measles and whooping-
cough In the acute suflocative t>pe the
prognosis is always grave, even m cases
uncomplicated with cardiac or renal disease,
while any coexistent affection of the lungs,
heart, or kidney greatly aggravates the danger
Walshe said he had known a case fatal m
forty-six hours, but while these patients often
succumb within a few days, they sometimes
recover oven after the condition appears hopeless
Acute bronchitis may pass into a subacutc or
chronic state, and is then liable to be associated
with various complications
2
18
BRONCHI, DISEASES OF— BRONCHITIS
DIAGNOSIS — The diagnosis of acute bronchitis
larely presents any difficulty Though it may
be abrupt m onset, and even attended with
considerable fever, there is not that initial ngoi
and characterise disturbance in ratio between
respiration and pulse-iate of pneumonia , while
the absence of fane crepitation or tuhulai bieath-
mg, the normal and exaggerated resonance ot
the chest, and the \videspre.wl piesence ot catrse
rales and rhonchi aie sufficient to differentiate
bronchitis from pneumonia,
Acute pulmoDfiiv tubouuloHis may closely
simulate, md foi a time be UKlistinguishablf
from, acute bioncbitis High pjioxia and
gieat prostration with caily deluium, while
not excluding simple biondutis, suggeht acute
tuberculosis, the occurience of hoimonhagcs
may assist the diagnosis in doubtful cases
(Wilson Fox)
It is, however, necessary to bear in mind
that bronchitis may be pronounced in the
early stages of typhoid fever, measles, w hooping-
cough, and more rarely \anola, scarlatina, and
other affections, the indications of which must
not be overlooked Tlnib the initial laclny-
raation, conjunctival injection, snee/mg, and
rhmorrhooa would leaf! to the suspicion of
measles Headache, gcneial malaise, the
peculiar rise of temperature, tenderness and
gurgling in the Tight iliac region, enlaigement
of the spleen, the characteristic rose-spots and
other indications oi typhoid tevcr should be
eliminated The aching in the lumhai legion
in variola and the soie throat of scailatma
and early appearance" of the lash seldom leave
one in doubt foi any considciablc period
Whooping cough may closely simulate simple
acute bronchitis, and, pnor to the develop-
ment of the chaiactciistic crowing, may be
indistinguishable
TRKATMPNI' -In the milder toim oi humchilis
of the uppei bionchial tiact — tiacheo-bicmchitis
— domestic lemcdies for a cold on the chest
usually suffice, and these only call foi mention
The mustard and hot-watei toot -bath, Ihe
application to the chest of a mustard poultu e,
or hot fomentations spnnklcd with tuipcutmc,
followed by a Dover powdci, and an aperient,
and some simpl*1 diaphoretic mixture such as
sweet spnits of nitre, and small doses of
ipecacuanha, will often ptove sufficient to
relieve and shorten the attack If the patient
cannot remain indoors for a day or two, it ife
necessary to avoid diaphoretic remedies, which
render him more susceptible to cold, and involve
a risk of conxertmg a slight bronchial attack
into the much giaver general bionchitis of the
smaller tubes, and tor this reason a Turkish
bath in the initial stages of bronchitis is
attended with a new nsk
In severer attacks more active measures aie
needful , and it should be ascertained whether
the bronchitis is a primary affection, or secondary
to some constitutional condition 01 other disease,
eg Bnght's disease, which would call for appro-
priate measures
Ju acute primary bronchitis the patient should
be con hned to his bed, and the temperature of
the room maintained at about 62" to 65r F
We have seen that the first stage IN due to
vascular encivation and engorgement of the
mucous membrane Thus the < hief indication
is to comb.it the diy and congested condition
by improving vasculai tow and inducing freer
secretion
At the outset a large mustaid and linsecd-
mcil poultice should be applied to the fiout
and back of the chest, this being leplaced by
simple linseed poultices aftei tin1 mustaid has
sufficiently stimulated the skin to piodueo
thorough leduess A stcam-mhaloi, with com-
pound tincture oi bcn/oin 01 tnutuiuol bella-
donna added to the hot watei, often affords
reliei A moist .itmospheic is not only i'om-
foiting to the patient, but seems to mateiialU
icheve the <hy, hack in «; tough, but when a
steam-kettle is used, it must be lemeinbcred
j that the steam may condense on the bed-clothes,
I and special taie is needful, bv ensmmg the
maintenance oi the tempeiatme oi the apait-
meut, to obviate the nsk of a chilling effect
on the patient Dining the eaily period in
the attack the (hugs that aic most lehed on
) aie taitaimcd antimony and ipecacuanha, apo-
• morphia, 01 squills, to pi omote bionchial secie-
Ition, togethei with citrate of potash, or acetate
, of ammonia, spmts ot nitre, 01 some othei
I diaphoietic If theie is biomlnal spasm,
tinc'tuie of lobelia oi belladonna, citrate of
cafloin, chloial, 01 opium may be added, but
should be cautiously used, especially in children
and in the old 01 feeble
As soon as the dr}> stage passes oft and
sedition commences, antimony and the dia-
phoretic remedies may be discontinued, and
stimulant expcctoianls, such as caibonate ot
ammonia with seneira, squills, euphorbia pilu-
hieia, 01 small doses oi iodide oi potassium,
substituted At this stage the preparation of
opium and direct sedatues to check the cough
which is due to the accumulation of secretion
in the tubes should be avoided
When the srnallei tubes are extensively in-
vol\ul and the amount ot secietion is very
considerable*, the patient must be carefully
watt hod for any indication of caidiac failure 01
pulmonary collapse In weakly patients with
impaiiccl licuit-ac-tion it may bo necessary to
lesort at once to alcoholic and othei stimulants,
such as digitalis, strychnine, or ether
If the bronchial secretions tend to collect in
the smaller tubes and pulmonary collapse IH
threatening, it may be desirable to induce
vomiting by the administration ot sulphate of
zinc or by repeated large doses of ipecacuanha.
Depressing emetics should be avoided
BRONCHI, DISEASES OF— BRONCHITIS
19
With threatening apnooa, the use of oxygen
inhalations, or, on rare occasions, venesection,
may bo indicated It ih hardly necessary heic
to give directions in regard to diet in bronchitis,
beyond emphasising the impoitance ol keeping
the patient on low diet in the beginning of an
attack , for the gastio-intestmal tiact w always
more or loss dcianged, <uid calls foi appinpn.tte
tieatmcnt
II rilKUMf' HliONClU'JIh IN VlllM IS
Jtiiwiut,\ -C/troiiH ttionehiti* is duo to mui h
the same, though generally moic; pcisistcnt,
causes as the acute iorm , but the influence oi
predisposing i.utors and constitutional condi-
tions is inoie potent, and is moio usually the
essential cause of thodiionu affection Moto-
over, chronic bionchitis is distinguished lathoi
bj its protracted com so and secondaiy com
plications than by any spec lal clinical featmos
In some cases tiequcnt su)>ai ut(» attacks, by
incicasmg the bus<vptibility oi the indiMclual,
and resulting in a gradual petinanent nnpan
men! of the tissues, pass insensibly and without
any line of demarcation into the clnonic form
Thus chronic bronchitis mav iollo\\ lepeated
attacks oi acute hionchitis, o) may be chronic
from the beginning It is usualh met with in
the aged, the "wmtei cough" oi old people
recurring from vear to yeai throughout the
colder months Vauous diatheses, siuh ,is
syphilis, gout, and lenal dise.ise, he(irt affections,
especi.illy disease- of the initial vahe, aneurvsm,
and ehionu lung affections, such as phthisis,
emphysema, and dilated blow In, and ilmost any
condition impaiimg genet al health, piedispose to
chronic bronchitis Hut a mild foim is also
met with in clnldien and young adults who
suffer pciiodiLiilly from recunent (.itatrhal
attacks, eitliei on the slightest exposuie, 01 it
inaj be associated with nastio-intestmal dis-
turbance Chiomo bionchitis is also \CTJ
common ui xvoikers in dusty oct up«itions, null-
puff npholstoieiN, hakcis, colheis, etc , and is
often associated with ihionu alcoholism
J/ORBID AAA inv} --The miuous mcmhiaiic ol
the bronchi in ch ionic bronchitis is smooth,
shining, and oi <i slat\ ificj* 01 daik ])inple
colon i, a hrightoi coloui being oltcn piesent
in post-mortem examinations, due to an acute
exacerbation whuh so often causes the fatal
result Close? examination \\ill show the open
mouths of the dilated mucous glands like pin-
point depressions The mucous membrane is
often thrown into folds by the accumulation
of cellulai strut turos beneath the basement
membrane, and the epithelium consists either
of the single layer of flat germinating cells or
heaped-np collections of transitional cells, fully
formed ciliated epithelium being generally
absent. The smaller bronchi are filled with
sticky yellow muco- purulent secretion which
oozes from the open mouths of the tubes on
section of the lung In uncomplicated chronic
bronchitis the muscular coat w hypcrtrophiod,
and the tunica ad\entitia thickened from cellulai
mhltiation, which also extends to the pen-
bronchial and pen-vascular hhious tissue The
cartilages aiu usually atrophied, or have dis-
appeared entirely In old patients they may
uudeigo calcai cons degc»neration The lungs
are usually emphyscmatous, and in very chiomc
cases \uth dilatation of the bronchi the muscular
"coat may have disappcated The mucous mem-
brane mav be ulcerated in icutid bronchitis and
in bronchicctoftis The lymphatic glands are m-
vanablv enlaiged and pigmented, and frequently
easeatmg The heart, and especully the light
ventucle, is generalh dilated, and the liver,
spleen, and kidneys aic> chiomcally congested,
and the seat oi hbioid degeneration
tf) US'/MATS -The svmptoms \aij considerably
in different cases, but main!) lesemble in
chaiactei those oi the acute foim, especially
modified b\ <oe\istent affections In the mildei
forms of the common winter cough oi old people
at hist the only complaint is cough with muco-
, pmulent expeetoiation and slight dyspnwa on
j exeition, ui in the eaily moming, unless theie
) is rnaikcd coexistent emphysema Theie is no
pain 01 te\ei in the earlier stages With the
1 retuin oi waiinci weather tin* attack passes oft
j completely, only to retuin with the lecurrence
! of cold and changeable climate The affection
i mav continue in this mannei for several years,
| but gradually djspnu-a on the slightest exertion
j is noticed as the attacks nit lease in so\enty,
| and the cough, mste.ul of disappearing during
the summer months, tends to peisist all the
I ye.n lound, the incessant cough and purulent
j e\pectoiation distui lung the patient's sleep, tho
, patient's health and stiength being £iaduall\
uudcimmcd
In the }ouni£ and in healthy adults the
i mildei cases generalh subside t^iadually with
complete com ilescence , but when once chronic
bronchitis has become pi oncmnecd and well
established, the pathologic al structural changes
whuh aiise lendei complete recovery scarcely
possible
/'/ns/t \i S/frV. — The chc-st may be moder-
ately distended without alteration in shape ,
but patients \vith old-standing chronic bionchitis
are almost imariabh c«mphysem«itous, in which
case the chest is unisidciahly distended and
b.urel-shaped the icspiratorv movements are
limited, expnation being prolonged, the per-
cussion-note is hypei lesonant and clear , the
hieath-sounds are harsh and loud , deep-toned
ihonehi, high-pitched scuicahng, piping sibilus,
largo and small rales, or bubbling, according to
the varying conditions of the tubes, are con-
stantly to be heard, while finer crepitation may
often be found at the bases
The expectoration is very variable in quantity,
being muco-purulent, and sometimes streaked
20
BRONCHI, DISEASES OF— BRONCHITIS
with blood from the luptuie of small bronchial
vessels
COUBSE AND ErExr — In the milder cases the
general health may not be gieatly impaired ,
but in course of time, especially inhen tho lungs
have become emphyseinatous, the heart becomes
dilated, and cvideneo of caidiae iailuie IH shown
by chiomc gastiic catarrh, enlaigement of the
liver, and in some cases by albuminous urine
These secondaiy ((implications aie no doubt
largely duo to the attei turns winch are the1
real cause of the bionchitis Vaiious othei
pulmonaiy complications, Mich as* bronchiectasis
and chronic mtetstitial pneiimonu, aie liable to
occur, and the patient boonei 01 latei succumbs
to a geneial failure of health and strength,
unless an acute exacerbation, which is \e»y
liable to anse, or some internment affection,
carries him of}
.Z)/^r;Aos/s — The cough and expectation
without consolidation of the lung usually leaves
no doubt as to the diagnosis From pleurisy
it is distinguished by the persistence oi v>cal
fremitus and resonance, and leapnatoty mmmur,
and by the absence of bulging, and by the
presence of the laics, fiom pneumonic con-
solidation, by the absence of complete dulness,
tubular breathing, and bionchophony
The conditions which are most liable to cause
difficulty in diagnosis are tubeiculous deposits,
and bronchitis due to the piesenee of ancui^sm
or of new giowths piessmg on th<» bronchi
J>R<H,MV* — The prognosis depends mainly
on the ago of the patient and the coexistent e
ot complications Once established, it is only
in the comparatively }oung and robust that
complete recoveiy can he hoped for In older
patients the presence oi well-maiked emph} scma,
bronchiectasis, 01 any vahulai heait affection
must add to the dangeis of mtei current
affections or a( ute e\acerb.itious
CIIMCAL \AKIEIIKS
The condition of the muscle ot the light
heart is of even greatei impoit than the
integrity of the tardiac valves, for the lattei
defect is often largely discounted by com-
pensatory hypei trophy, wlicieas a degeneiated
and weak caidiac muscle is unable to cope with
the demand for inci eased eneigy whuh is made
on the right heart in bronchitis, and often fails
to respond to any ticatment
The above dcsmption applies to the gieat
majority of cases of \arying severity Atten-
tion has already been directed to the clinical
importance of various diatheses and diseases
which predispose to bronchitis Often enough
the bronchitis is only a prominent symptom of
some such underlying disease, and some wnteis
distinguish vanoiiH clinical types, such as renal,
gouty, syphilitic bronchitis, and so forth
But there are certain forms of chronic
bronchitis which call for special mention, viz.
(a) Uronehoi r/uea, characterised by excessive
secretion of glairy, semi-transparent matter,
like white of egg mixed with water, containing
gieyish or yellowish -green masses, or the
expectoration may be thin, watery, and clear —
brondu»rhtea scrota The cough and dyspnoea
arc usually ptvroxysni.il, eithei limited to an
hour or two on awakening in the morning, oi
coming on at mteixals of sexeral houis dining
the daj, tho amount expectoiated being veiy
large, sometimes as miuh .is thiee or foin
quaits m the course of the day Dining the
paroxysms, dyspnoea is uigent, but m the
mtcivals, and in tact throughout the day in
some eases where the cough and e\pectoiation
only oecui on waking m the moinmg, dyspnoea
may be absent 01 scaieely noticeable Rales
and ihonclu aie audible befoie and dm ing the
penods of expectoiation , but in the mtcnals,
until the sedetion has le-ac cumulated, the
auscultation may ic\eal compaiatncly tew
ad \entitious sounds These cases .ue almost
imanably associated with some degiee oi
bionchial dilatation
Patients maj coutmuc to Irse with little
alteiation in then condition for many }eais,
but giadually the symptoms become more
pionounced, the dvspucra inci eases with a
tendency to asthmatic symptoms, and genentllj
failuie of the c 11 dilation, inci easing oedema,
cyanosis, and impairment ol health and strength
(l>) fhyC/uonu tttonihttt\ -The tatair/ie ice
of LcL'imec is chai.u tensed bv paroxysms of very
tioublesome and sexeie cough, with xeiy scanty
expectoration of small masses of tough, viscid,
try aline mucus The affection is almost always
complicated hj emphysema, and is usually
associated with gout It is geneiallv legarded
as due to congestion ot the tubes, but
"bionchial spasm is doubtless largely assouated
with the congestion, indeed, bionchial suscepti
hiliU and bionehial nutation ate its unmistak-
able, ctiological factois" (Ewart)
(V) Foetid lh<mcfntn> — In the eouise of a
long-standing ehioinc biouchitis, the expeetcna-
tion occasionally assumes almost suddenly, and
without appaient cause, a dirty grey coloui
with a peculiar putrid (xlom Putrid expectoia-
tion is met with in bionchiectasis, gangrene,
and othei distinctive lesions of the lung, and
in peifoi.itmg ciupyema, and is usually due to
one oi othei of these affections, but lately it
supeivencs in uncomplicated cases oi bronchitis
Its onset is generally attended with rigors, and
with all tho appearance of the occurrence of
acute bronchitis superadded to the chronic
affection, with fever oi typhoid character, and
attended with intense depression The ex-
pectoiation consists of a gieyish-white alkaline,
putrid, muco-pin ulent fluid, with a peculiar,
sickly, characteristic odour which is said to
suggest the smell of acacia blossoms The
amount secreted is very considerable , the sputa
BRONCHI, DISEASES OF— JUIONCHITIS
21
separate into an uppei fluid layer covered with
froth, and a lower dirty luyei containing yellow-
ish plugs varying 111 bi/e from a nnllet-BCcd to
a bean, "Dittiich'b plugs" These masses on
examination aie found to be made up oi pus-
cells, oil-globules, tatty acids, leucm and tyiosin,
and dctntus Vaiious inicio-organisms have
been isolated fiom the plugs, leptothrix pul-
monalis (Loydon and Jaflo), a short slightly
cuived h,icillus xx Inch on culture gives an odoui
like that of the sputum (Lumnic/ci), and shoit
thick icxls icsc'inMing bacillus coll (Hitzig)
Yiichow and (lamgoo obseixed that these
masses stain blue xxith iodine
III the unldei ioimN w hen the patient's stiength
and geneial condition is good, the piogiuisis is
fairly favomahle, but in se\eic cases it is liable
to lead to xanous dangerous complications, such
as pneumonia, bicmehicctasis, gan^ic'iie, etc , with
usually a fatal lesiilt Death has cxcmml in
some cases fiom the foimation of metastatic
hi am «ibsc ess, bill moie usually the patients
sucdimb to a geneial depiession and collapse
(<{) 7Vr»sfff Jtx>n<httt^ -The special featuic
ot this pecubai <ind tale ioim oi bionchitis is
the expector.it ion of bianclunu casts of the
smalloi biomhial tubes Somewhat simil.u
casts or moulds of the bronchi may be iound l>y
extension do \\n\v aids ot nieiubianous larxngitis,
and aic o( casioiiall) found in pneumonia, phthisis,
eiysipelas, .uid othoi diseases, 01 as the icsult oi
hex 010 untiituiii by the inhalation of steam,
ammonia, etc , and iilmnoiis blood casts max be
expeetenated in h«emo])t>sis. From all those
conditions tine plastit bionehitis ditteis in
pathology and symptoms
EttoltKftj — The cause ot the affection is not
known, and it is possible that in diftcient (ases
the etiology is not identical Its appeal ance
seems to be due to some ichosyneiasy 01 peeiihai
teatuies on the puit ot the sutleiei It has often
been associated with .1 piedispobition to tubei-
eulosis, but it may attack those appaiently in
lobust health Tho exciting causes of the
attacks are much the same as in oidmary biou-
chitis, geneially ocdiiiing in the earlv spimg
months and aftei exposiuo to cold It is neatly
twice as < '0111111011 in males as in females, and,
xvhile it mav be obsoixcd at all ages, is most
frequent between twont} ,ind foit\
SynifitoniK — The majoiity of cases aie ot the
natuie of a clnonic bionchitis, with special
feat in CH, but, especially in childien, acute attae ks
lasting irom one to foui weeks oce ui Usu.ill^
the onset lesembles simple Incnu hitis, with a di)
cough or with slight mucous expectoiation, and
blight constitutional disturbance , aftei a variable
period, xxith the formation of the hbnnoub casts,
severe hacking i ough, dyspnuM, rapid breathing,
and pyiexia supeivcne, iollowed by the expec-
toiation of the arboiescent moulds
The sense of suffocation and hvidity may be
pionounced if the bionchi are extensively im-
plicated, and the patient fiequently complains
of pain in the side, but with the expectoiation
of the casts theic is generally an immediate
tempoiary relief Kxpulsion of the caste is
followed by luemonhage fiom the bionchi, vai}-
mg in amount fiom a lew stieaks to several
ounces The casts appeal in the sputum rolled
into .1 solid mass, mixed witA ordinary riiuco-
puiulent mattci , but x\hen placed in water the
casts umoll and display then charac tcribtu
f 01 m
In sex'eie cases the mtt licience with respna-
tion is so conn* ieiiible that total suffocation may
ensue befoie the casts ha\e bc-cn e\pellc»d In
othoi cases the course ot the affection is le&s
sex on*, vnd the att.u ks may List for weeks 01
months, or iccui at mteixals toi man} yeais
The illustiation on p 14 is horn a .specimen
ot those hnclx blanched fibrous cabts in the
Museum oi the Hoxal College oi Surgeons,
London Thej weio exj)C'(toiatc»d by a boy aged
olexcn He had alwaxs been delicate, and when
about six >eais old had an attack of mmienza
Fiom that time he w.is subject to cough and ex-
pectoiation, and spat up pieces oi membrane at
mtcMals His mothei's fannlx was healthy,
but on the iathei's side theie was a stiong
tubi>iculai tendency, and two ot the six children
had dic'd, one of cioup, ono ot consumption
The1 ph}sical signs aie those of severe bion-
chitis, togethei wjtli those1 icsultmg iiom more
oi less extensive occlusion of the bionchi The
casts nexei extend to the tiachoa, and raiely
exceed a goose-quill in sixe If only a fex\
biuallci bronchi aie mvohed, special physical
signs m<\y be mipciceptible, but usually thcie is
absence ot breath-hounds ovei the implicated
areas, tnstly tiom the blocking of the bronchi,
.ind secondly fiom collapse of the coiiebponding
an-xosicles If the aiea mxolvod is extensive,
theie may be dulness on peicussion heie, eithci
hypei Tc&onance elsoxxhere, or the lespiratoiy
mox'emcMits may be diminished, and retraction of
the loxxei chest-wall maybe present duiing m-
spn.ition As the rasts become loosened, rales
01 sibil.iut 01 whistling hiomhi may appear, and
a flaj)pmg sound has been obseixed
The casts xaiv m length, fiom being mere
fragments, to as much .is ioiu or fixe inches, oi
oxen, as in a c.iso of IJiegol's, six inches, but
gonoialh they are one 01 two inches long, and,
xx hen washed tice tiom aclheient mucus and
suspended in watei, ioim a pcitcct icproduction
cast ot the pait ot the bionclu.il tree The
laigei stem is less in cncumleienco than the
tube in which it is ioimed, it raiely exceeds
.1 goose quill m size* , and folloxving the faul>-
divisions ot the bionc hi, extends downwards to
then finest ^unifications, so that, accoiding to
Bicuuei, the1 minutest teimmatioiib may IH» bulb-
ous fiom being moulded in the nifundibula
Excepting the smaller filaments, the casts are
hollow, the lumen being usually filled with
22
BRONCHI, DISEASES OF— BRONCHITIS
mucus and bubbles of an A trans vcisc .section
shows that the casts are evidently deposited in
successive layers, for they aie always found to
consist of concent no lamina; of a fihiillated 01
hyaline basis, with nnmeious epithelial cells,
leucocytes, oil-globules, granulai debus, ocea-
sioual Curschmann's spnals, and Chaicot hoy-
den's crystals in its meshes , blood-cells maj be
found on the surface The disease is ( ommonty
termed fibimous hiom hitis, nuclei the impiession
that the casts are composed of hhiin , but it has '
been shown by (handy that they aie composed
of mucus, and not of fibrin, and MIC analogous
to the casts ol mucus colitis Wilson Fox status
that they aie soluble in alkalies and in lime-
water
Ti catment -- Little can be said in ia\oui ot
any special ding 01 method oi tioatment in
those cases, but during the attack the patient
should be placed undei the general conditions
and ordmaiy ti catment of a< ute hionchitis
Inhalations of ammonia, of fmelj spiajed lime
watet, ot solutions ot .in alkaline carbonate, and
the mteinal admnnstiation ot loduleof potassium,
cieasote, turpentine, are said to ha\e been em-
ployed \vith success
Emetics may ta\om the expulsion ot the
casts, and Oslci suggests pilot ai pine might be
useful, as it mci eases the bionclnal secietion
In the inteivals between the attacks geneial
hygienic measiues and the use oi tonics may
perhaps prevent the attacks being so trying to
the patient , but Walshe believes that no drugs,
nor the best of health, noi the most favouiable
climates have any beneficial influence in modify-
ing or pi even ting the attacks
The vaiying phases of chionu hionchitis
render it difficult to lay down any definite com so
of treatment, and the remedies and method oi
treatment of chronic bronchitis aie so veiy
numerous that it is only possible to mention a
few, while endeavouung to suggest the lines of
treatment that may be most suitable lor the
great variety of cases in which chioinc bronchitis
is the main feature The most essential point
is to discovei, and, as iai as practuablo, remove,
the cause of the bronchitis in any particular
case. Thus if the affection is duo to the inhala-
tion of imtating particles of dust in his \voik,
it maybe neccssaiy foi the patient to change
his occupation , if it is due to damp and un-
healthy surroundings, he must be placed in a
more suitable environment, if to Blight's dis-
ease, renal inadequacy, valvulai heart-affection,
syphilis, oi gout, ticatrncnt appiopnate to these
diseases is essential ioi lehei
In the mildei and more chronic cases reliance
should be placed mainly on general hygienic
treatment, a\c»idmg when piacticable the use of
drugs, unless specially indicated or requncd foi
the purpose of overcoming any complication or
constitutional taint But acute or subacutc
exacerbations generally call for moie active
treatment on lines similar to that in acute
bionchitis
We may bucfly considei the methods ot treat-
ment under foui headings (1) General and
climatic , (2) medicinal , (3) local applications ,
(4) countei -nutation, mtissage, baths, etc
(1) General and Climatic — The need foi
wdi in clothing, with flannel gat men ts next the
skin suited to the season, seemingly so obvious,
is not always observed, and may have to be im-
pressed on the patient, while the gre.itest care
should be taken to avoid exposui e to c old winds
and lapid changes oi tempeiatuie \bundance
oi iiesh air, eithei out oi doors, 01, if that is
impossible, in \\ainiedaiicl well-ventilated looms,
is oi the hist nnpoitaiuc Too often sufluieis
horn bionchitis mciease then susceptibility, and
even chiectl} maintain then complaint, by
shutting themselves up in close, stutty looms
Apait horn the vaiums aftcctions v\lmh may be
the essential cause oi the complaint, any mi-
panment of the geneial health tends to pi event
lecoveiy, thus anv coexisting atlection demands
attention , especially does this apply todvspepsia
and constipation
Nothing moie gcnciallv pioxes benefit iai than
change ol climate Many cases do IM 11 by the
sea-side In England the south coast furnishes
many suitable places in the vvmtei, such as
Toiqiifiv, Falmouth, Bouinemouth, Hastings,
the Scilh Jhli'h, Mo of Wight, \\hile tin- Kicnch
Kivieia, Burnt/, Madena, 01 the northein
Afucan shoie ma\ piove moie suitable to th >sc
\\ho aie able to go faithoi afield But it is \\ell
to lemembei that a vciy laige numbei of pel sons
aie always pi one to deiangemcnt of t he liver and
stomach .it the1 sea-side, and that this is one of
the conditions which it is veiy necessaij to avoid
in bronchitis Foi these a \\aim, equable climate
such .is that oi Mai \ein, ('l)l ton, oi dry hill-
aii, 01 the Lake, of (Geneva, Botchghora, 01
Egypt may be bettei suited V.mous Con-
tinental spas, such as Kms, Soden, Mont Dorp,
Carlsbad, Spa, etc , aie beneficial, esjx'ciallv in
gouty cases
The diet should be light and nutritious, and
the state oi the .stomach and livei, and any
tendency to constipation, should leceive careful
attention
(2) Medicinal —In the acute exacerbations
and in the very chronic eases the secretions tend
to be scanty and the expoctoiation veiy tenacious
In these conditions, for me leasing the expectora-
tion and making it more fluid, iodide of potassium,
uaihonatc of ammonia, apomoiphm, ipecacuanha,
coullana, and utiate oi potash aie useful, eg
R Ext cocillanaa fl n\xx , apomorph hydiochl
gi. ;ff, syr prun \irg ,"j , •«! dest ad Jss
Tort quo; hor Oi, Amnion caib grs iv .
tinct scylhe 3j , aq. clilorof ad ass Qnatt
qu& hoi a
If thcic is a tendency to bronchial spasm,
iodide of potash, caftcin, lobelia, myrtus chokan,
BUONCHJ, DISKASES OF— BRONCHITIS
23
giindcha robusto, or bromide of ammonium may
bo especially indicated When the cough w ex-
cessive and aimless, and due largely to rncro
bronchial imtation lathci than the amount of
secretion to he expectorated, some sedative
should he combined with the othei remedies,
such as moiphme, codeine, compound tinctuic
of camphoi, belladonna, stramonium, hydro-
cyanic acid, etc — e <j li Ext hq grind rob ,
ext hq inyrtus chekan, aa N\ \ -xx , tmet lob
i-th H\X , aq chloiof «ul z}\ Qiiait qua;
horn
When, on the contraiy, the bronchitis is
associated with profuse muco-purulentexpc-ctoia
lion, the various piepaiations of opium and
other dnect sedatives should nevei he given
without the most c.ireful consideration, and then
only with great caution, and in combination
with some stimulant expectorant, such as the
(aibonatc 01 ehlonde ot .tmmonium with squill
and senega In these lase* thcie IN often con-
siderable general \\eakness, tot which non,
quinine, aiseme, and dilute mineral acids ate
desirable, especially in those cases in which the
expectoration continues to he excessive despite
the exhibition ot the toregomg lemedies, and in
these conditions lesoit may he had to \aiious
gum resins .uid othei expectorants, examples oi
which aic the balsams ot LViu and tolu, Canada
balsam, ammoniac. urn, copaiba, ( ubebs, cieasotc,
t,ir 01 tar-watci, teicbcne, tuipfntme, tcipine
hydidto, oil of sandal \vo(Kl, etc , etc Wilson
Fox has iceommended the tincture ot laiix
Kuiopoja as a ^aluable lemedy m this class ot
cases, and also sulphui gi\en internally as an
electuary, combined \vith bitattiate oi potash
Foi the chronic bionchitis of the aged, Whitla
has found ammoniaeum a most valuable e\
peetorant , it iehe\es whccying and piomotes
expectoration
Ood-hvei oil is otten singularly valuable in
^ery chronic cases, especially in those attended
with pi of use expectoration Not only does it
improve uutiition, but its use is often followed
by a remarkable diminution in the secretions ot
the htonchial mucous mcnibiane when all othei
lemedies ha\e been tried without effect Nor
should we iorget that the weakness and dilata-
tion of the right side of the heart, with which
chronic bronchitis is so often associated, tails lor
such remedies as digitalis, strophanthus, and
other
(!J) Local Applications —-Local applications
include various inhalations and spiays, and
mtratracheal injections Foi steam inhalations,
benzoin, teiehcne, oil of S< ot< h pine, and creasote
are commonly employed , thus a thud drachm of
the compound tincture of IWIIEOIII may be mixed
with a pint of hot watei at 104" V and the
steam inhaled If there is pain 01 bronchial
spasm, two or three minims ot chloroform,
conuim, or laudanum may be added With the
pine oils and creasote it is well to add carbonate
of magnesia, a useful formula being creosote,
}]{ x , or oil of Scotch ot Swiss pine, fl^xl -Ix ,
light carbonate ot magnesia, 20 to 30 grs ,
watei to 1 fl oz for each inhalation Atomised
aqueous solutions of ipecacuanha wine as recom-
mended by Murrell, chloiide oi ammonium, very
weak tai -\\atei, used with a Richardson's oi
othei ioiui oi atomiser, oi terebcne, eucalyptol,
menthol, 01 thymol, dissolved in vaseline oil,
may he mentioned, us well as the wearing of a
respirator \\ith a small quantity of cotton-wool
oi sponge upon which has been dropped some oi
the volatile exjfectoiant
The value ot mtiatracheal injections, by means
ot a synnge with a long suitably curved vul-
canite nox/le, m certain cases meiits careful
consideration , the method is little piactised,
but is highly commended by those who have
had recouise to it It is particularly in patients
with tenacious muco-purulcnt expectoration, and
in putud biomhitis and bronchici tasis, that the
method is called toi (luided by a laiyngoscopic
mirioi, the no//le is m>iitlv but quickly passed
below the vocal coids and the svimgo emptied
Commencing with a drachm toi each injection,
the patient soon learns to tolciate two or three
di acinus being thrown in at a tune An oily
j menstiuum, eithei olive 01 almond oil, or liquid
] vaseline, in which menthol, teiebene, eucalyptol,
| 01 neasotc have been dissolved (about three to
I h\e giams 01 minims to the fluid dtachui, scpar-
| ately 01 in combination), forms a suitable mjec-
! tion tiiamgei JStewait'h fonnula foi bronchi-
j ectasis is menthol, ten paits , guaiaeol, two
parts , with olive oil, eighty-eight paits , a fluid
dtaehm being injected daily Anothei suitable
fonuulais — chloiotorm, 11^\\\ , balsam ot Peru,
DIJ , oil of eucalyptus, TjiJ , ca&toi oil to jjj ,
half a diachin being injected once 01 twice
daily
(4) Ertei nal Applnation^ J/rtA?a//f, and Rath*
- One of the most impoitant means ot relieving
chronic bronchitis is countei-imUition, long con-
tinued lathei thiin seveie Of VMHOUS stimulat-
ing liniments, we may mention tlio compound
c'amphoi liniment, tuipentine liniment with
acetic acid, 01 a liniment containing cautharides
oi capsicum, 01 the application of iodine in solu-
tion, 01 mustard oil will be suitable tor the pur-
pose The vigcmms rubbing ot the skin in the
apphc ition of liniments is no doubt in itself
beneficial NOT should we oveilook the un-
doubted value of systematic massage and Swedish
exeicises in .1 large proportion of cases In
young adults, cold baths followed by fnction
with a coaisc towel, needle -baths, in fact a
course of "hydiopathie tieatment," may be
helpful in restoimg vascul.u tone and the
patient's geneial health, \vhile materially assist-
ing in the treatment of the bionchial affection
HI BRONCHITIS IN CHILDREN
Bionchitis occurring in children,
BRONCHI, DISEASES OF— BRONCHITIS
while essentially similar to the affection in the
adult, is nevertheless distinguished by certain
predominating clinical featines The actual
cause of acute bronchitis in child) en is usually
exposure to cold, but it is in the pooily clad,
under-fed, ill-housed childicn of the pooi who
aie brought up in duty, ill- ventilated, ovei-
crowded i corns th.it the woist fonns aie ob-
served Individual predisposition laigely inilu-
ences the nature of a cat.urhal attack, and while
one child is prone to catarrhal affection of the"
upper respiiatory tract, unothei tends to siiftei
from bronchial attentions, and,* again, othcis
from gastio-intestmal catairh
Rickets, dentition, and intestinal catarrh aie
important etiological tactois, and, as Ashby
remarks, during the time that a tooth is being
cut, children seem very apt to Buffer from
catarrh, which in wintei affects the bronchial
tubes, and in summoi the intestines pressure
of the tooth on the gums seems to act icflexly
in producing a catairh, sometimes \vith moie 01
less spasm as the child becomes whee/y at night,
sibilus being heard all over the chest, while m
the morning it will be perfectly well
A not unimportant factoi in the occurienee
of bronchitis is bucc.il icspnation from nasal
stenosis The susceptible bronchial mutous
membrane of childicn is unable to withstand
the habitual inspiiatiou of air unwarmed and
unmoistencd by noim.il nasal i expiration, and
consequently frequently recurring bronchial
attacks aie generally obseivcd in childicn with
post-nasal growths
Whooping - cough and measles are generally
accompanied by bronchitis, the bronchitis vciy
often attacking the finer tubes, and being
mainly responsible foi the mortality of these
diseases in young childien
A'yjtf/'^oj/s — Mild, uncomplicated bionclntis in
children is attended by much the same tiam of
symptoms as in the adult, but theie is a mm h
greater tendency for the catari h to involve the finer
bronchial tubes and the air-vosicles, a condition
which is always attended with gravel symptoms
and considerable risk to life, owing to the weak-
ness of the muscles of respiration (including the
bronchial muscle) and the yielding nature of the
chest- walls, foatuies which moto especially chai-
acterisc rickets In slightei attacks the pulse
is moderately quickened, and the teiupeintiuo
raised two or three degiccs above notmal , but
whenevei the biomhial tubes are extensively
implicated, the pulse is hard, the temperature is
four or five degrees above noimal, the lespini-
tions are quick, sometimes amounting to 70 or
80 a minute, with the ala» nasi distended and
working The chest is expanded in the position
of inspiration, the shoulders raised, rcspnation
being chiefly abdominal, and the accessory
muscles are brought into play, and the an
failing to distend the lungs, the dyspncva is
attended with recession of the chest -walls,
especially of the epigastric and lower lateral
legions The skin becomes hot and dry, and
the child restless and tossing, first to one side
and then to the other, or having to be carried
ahout, and constantly changing its position
The invasion may bo usheied in by rigors or
convulsions, and convulsions not inficquently
01 cur in the last stages of fatal cases
It is only the nnldei cases which escape com-
plications, especially collapse of the lung, broncho-
pneumonia, broin hicc tasis, ,uid emphysema , but
in young cbildien the onset oi the attack maybe
se\eie, \vith gieat piostiation, ugois 01 convul-
sions, bionclnal spasm, palloi and hvidity, and
pionoimced dyspnoea, w Inch may lapidly asphyxi-
ate the child befoic there has been tune foi the
development of complications
The pathological processes \\huh result in
collapse oj the lurn/ have aheacly been des< nbed
above (see p 15) The symptoms .ire not very
distinctive, unless the collapsed areas are in the
aggiegato sufhuently extensive to pioduce obvi-
ously increased lespiratoty embarrassment, fall-
ing in of the chest-wall, and dulness on per-
cussion , and even then it is always difhcult, il
not impossible, to eliminate1 the coexistence of
broncho-pneumonia, whu h in such cases is itself
the chief cause oi the severer symptoms
The occmienco of bioncho-pneumonia in the
couise oi acute bronchitis may be suspected
horn the cxaggeiation of all the symptoms
which usually lesult "The child is restless,
the cough shorter and moic hacking, the skin
hot and diy, the evening temperature usualh
reaching 103J 01 10 1° K with morning remis-
sions of sevcial degrees, so that the fever assumes
a leimttent type , the dyspmra is usually gieat,
the respirations numbering forty or fifty, but
vaiying with the amount of fevei and extent of
the lung involved" (Ashby) Examination of
the chest unfoi innately is often of very little
assistance in the diagnosis of this ( omphcatiou,
foi in place of dulness on peicussion there is
more usually hypei -resonance owing to the
cmphysematous lung sui rounding the pneumonic
patch, and it is tare to find complete dulness ,
indeed, a considciable amount of pneumonia ma>
exist in patches without obvious diminution of
the peicussion resonance Ashby draws atten-
tion to the fact that while rhoncln are heard all
over the (hest, over the pneumonic poitions
laics of a consonant 01 ringing character may
bo heard, which aie more intense and ringing
because they tiavel to the ear through consoli-
dated lung , and he states that even though no
consolidated lung can be detected by percussion,
the presence of consonant, intensely tinging
tales with a temperature of 103° or 104° points
almost certamlv to pneumonia Walshe points
to the greater diffusion of the moist rhonchi in
bronchitis as compared with pneumonia
THE DiAG$OMt> of acute bronchitis in children
is, as a rule, easy if suspected and sought for,
BRONCHI, DISEASES OF— BRONCHITIS
25
although there is seldom any expectoiation to be
seen, inasmuch as young childien almost always
swallow what they cough up There may In-
considerable laryngitis and glottic .is well as
bronchial spasm, sometimes causing confusion
with spasmodic cioup, but in bionchitis the
spasm is not so maiked, and the cough IN Jess
brassy and imging in chaiactci Laiyngismus
stiidulus is a iici \ous affection, which, hk<
bronchitis, is especi«illy pione to ocem in the
subjects of nckets , hut it i.s ac< oinpamed by
othei chaiacteristic signs, and is, moieovei, un-
attended \vith pyiexia, \\hich is ncvei «il)sont in
acute bionchitis incluldien
Simple broinhitis in children, as in adults,
may also bo snnul.ited by the invasion ot
measles, whooping-cough, typhoid fexer, gencial-
iscd tuboioulosis of the lung, and moie laielyby
Hcailatma and small-po\ The chiei points oi
distinction have ahe.uly been mentioned in the
section on acute biont hitis in adults, but it is
especially in children that difficulty in the e.tihei
recognition of measles and \\ hooping-cough is
likely to anse
/JAW,A^S/S — V( ute biom hitis is cspe< iall\ latal
dm ing the (list two yeais of life, and, speaking
generally, the youngoi the patient the moie
likely is a fatal tei initiation, paitiiulaily in
rickety childien The chief souicc ot dangei is
the liability to in\olvement ot thefmei hionchial
tubes, with asphyxia fiom extensne pulmoiiaiy
collapse .Hid broncho-pneumonia Yet childien
will sometimes ic«>\ci fiom A condition that is
appaiently hopeless Hilton Fagge states that
we must be cautious in giving an unfaxomable
prognosis in clnldien , it is surprising how lapid
maybe both tin pulse and the bi(athing, toi
two or three days togethei, in those who ulti-
mately lecovei completely
C/itomi Inonchiti* in children is compaiatuel)
ran*, since the ptocosses of lepaii ate moreacti\e
in them than in adult hie, while the \eiy acute
and sevcie attacks of acute bronchitis, fiom
which only incomplete icco\e.i\ is genei.illy pos-
sible, frequently end fatally before the chionic
stage is reached Nevertheless, susceptible and
delicate children aie veiy prone to suftei fiom
frequently recurtmg attacks of acute or sub-
acute bionchitis, which ultimately pass into a
moie 01 less peisistent chrome, aftcctwn In
the mildei cases they often lose their tendency
to bronchitic affection about the age of puberty,
and ultimately become stiong and lobust
When clnldien aio the subject of peisistent
chionic hi om hitis, it is almost invaiiably ac( om
pained by emphysema and biomhicitdsis The
chest becomes ban el - shaped, the shouldcis
rounded and high, tlie face pinched, and the
bodj thin The heart is dilated, the jugulai
veins large and prominent, and more or less
cyanosis is usually obseivod They aie very
liable to be camod off by an mtei current acute
attack, and are apt to become tuberculous
7Yu 4YV*A/ — The treatment of bronchitis in
childien is the same in pimciple as in the case
ot adults The tempeiatuie of the apaitrncnt
to which they ate confined should range fiom
64" F to 66' F , and in all but the rmldei eases
the an should be kept moist by means of a
steam-kettle A linseed and mustard poultice,
or hot ionif ntations, should In applied at the
outset It is necissaix to be careful not to
appl) poultucs oi foment itioiis too hot foi the
tcndu skin ot childien, 01 to use much mustaid
in the poultn c> , and in infant-, and young chil-
dren it is wejl to c online poulticing to the back
it theie is gteat dilheultv in breathing, as the
weight ot a poultice maj field a fiesb dangei
mstcdd oi pioduung the lehei desned
Tin diugs most telicd on aie ipecacuanha in
the toim ot tin powdei 01 wine, s)iup ot squills,
apomoiphia, and antimony Small frequently
icpeatcd tloses ot the taitiate of antimony 01
oi apomoiphia will geneially ic heve congestion
and aid scuction in the cailici stages It ib
undesiiahlc to push these 01 am diugs to the
point of \oinitmg 01 even nausea in the early
stiges Small doses of .u mute «t belladonna,
.1 minim 01 half-mini in e\ei) two hours, aie also
ot gieat seivice at this eaiH pciiod Bella-
donna, leconnnended by llingei and Mini ell,
has the effect of diminishing the scciction in
the bionchial tubes, and on this account is often
of much value in the bionchitis of children,
when fiom the fiee secietion both into the
bronchi and the pulmonan tissues theic is a
tisk of bioncho-pneumoma It is much piaiscd
on this account bj (Joutts in the tieatmcnt of
broncho -pneumonia, and 1 am able to confirm
his u,ood opinion ot it from my own experience
The diug should be i>iven with no timid hand,
the extiact in doses of yi J to J being piefer-
able to the tint tun, but its effect must be
watched, as it sometimes fails to relieve the
respiiatoiy embarrassment If cough is exces-
sive, small doses of biomide of potassium rnaj
be given It opium oi any of its picpaiations
aie considered necessary, they must be used
with gte.it caution Non- depressing emetics
such as ipecacuanha or sulphate of /me are
.jometnnes called for in the initial stages bcfoie
the sctiction has occuned, when the bicathing
is much impeded horn the sw clhng and engorge-
ment of the mncosa , they then may leheve the
condition bj aiding fiee seeietion and by empty-
ing an en ci loaded and distended stomach
Again, m latei stages, when the tubes .110 be-
coming choked by excessive senetion which the
little patient, either from weakness 01 fiom the
tenac ions < haractci ot the muco-pus, is unable to
cough up, emetics aie of signal seivice
The diet should be light and nourishing, such
as beef -tea, milk and milk -puddings, Benger's
food, and barley-water, and in all cases the con-
dition of the stomach and bowels should receive
attention
26
BRONCHI, DISEASES OF— BRONCHITIS
The importance of warm clothmtr, fresh air,
and protection from cold and damp as piophy-
lactic measures is obvious, eind only requncs
mention
INSAMI\ OF (!\A?*OSIS
A brain supplied with only p.uti<illy aerated
blood, like othei organs <>t the body under
smiilai conditions, is incapable ot perfect func-
tional activity, and the gi eater the coexistent
defects in the wain structure the inoie pio-
nouuced is the functional abci ration Thus it
IK easy to understand that it is t especially in
persons of ad\auced ycais that mental obscurity,
conf union and delniuin, and >anous intellectual
and emotional phenomena <uc apt to anse from
prolonged 01 acute cvanosis in bionchitis and
other pulmonaiy afle< tions, and in \anous toims
of cardiac disease Houston states that "the
insanity oi cyanosis fiom bionchitis, eaidiac
disease, and asthma is a lonu of dclnium with
confusion, hallucinations ot sight, sleeplessness,
sometimes suicidal impulses <md vague leais
These symptoms aie usually \voise ,it night,
and often end in mental toipor, p.issmg
into coma, and in some de»iee the mental pouei
is usually affected in most old persons with
diseases that pi event the blood being propcilv
oxygenated "
But there aie mmoi degiees ot ment.il dis-
turbances also due to cyanosis which do not
amount to actual insanity, eudencod by change
of manner, emotivity, suspicion Maudsley, in
discussing mental changes due to impuiities
in the blood, distinguishes thiee changes —
firstly, a general disturbance oi physu al tone
secondly, the engendeiing ot chiomc delusions,
and, thndly, in the uioie .icuto foims, acti\e
delirium In the aged the cyanosis and dys-
pnoea of capillary bronchitis cause mutteimg
delirium oi delusions, but in joung, strong
adults acute maniacal excitement is sometimes
obseivcd
From the insanity of cyanosis we must dis-
tinguish those cm ions «ases in which "altei-
nation" between insanity and, lot instance,
bronchitis oi asthma takes place " There are
cei tain cases of eh ionic bionchitis so called
which, by then peiiodicity and by their chion-
icity, appear to luue a distinct relationship to
nervous disorder , and, in con hi in at ion of this,
we would say that just as certain cases of asthma
alternate with other neuioses, so these cases of
chronic bionchitis alternate with the neuroses
\sthma may be distinctly found to al tomato
with insanity , as a rule the insanity with which
it altei nates is ot the melancholic type "(Hack
Tnke) The same alternation is sometimes
observed in chrome bronchitis of the type just
mentioned, and Tuke iciers to one such cose in
whom there had been two attacks of melan-
cholia, and each of these was associated with
freedom from the recurient bronchitis
Bronchiectasis
ETIOLOGY AND (IENBTUL CAUSATION 26
INDUCING CAUSE 27
MORBID ANATOM> AND PATHOLOGY 27
( JiiAiiAr-fEU OP SECRETION AND BRONCHIAL
CONTFVTS 27
CLINK *AL PHENOMENA 27
PHYSICAL SK.XS 28
DIAGNOSIS 29
PROGNOSIS 29
TREATMENT 29
tiee <i/s« RKKMIL, Couoii, KXPM TOUATION ,
H * \ioi*n sis . Li'Kdh, (JANURENE OK, LUNGS,
SYPHILIS OF , OHIEO - AuTiniorAiHiEs (Pul-
nwnnty), l'ihLR\, DISFXSRS ot (Empyinvi)
/)fHNiiUL\ Bioiulncctasis 01 dilatation ot
the bronchial tubes is secondai) to, 01 occuis
as an incident in, a variety of pulmonaiy dis-
eases In some cases the condition is masked
by the pnmaiy disease and umecognised during
life This is uspc>( Lilly the < a»e in the acute
hums when the smaller bronchioles are dilated
(broiic hiolectasis), and in the chronic form ot
the disease wheio theie is u'enci il and fusifoim
dilatition ot many tubes
In the moie typical c.isos the disease is easily
lecogmsed by certain piommeiit ,ind ch.iractei-
istic teatui es whuh entirely obscun the primary
disease
Ennio^ A an (iixiini CAi'btiiuy —In the
histories of patients who aie the subjects oi
brom hiec tasis we find the following diseases —
1 Acute or < hionu inflammatory diseases ot
bioncln, lumrs, oi pleura
(a) Acute and chronic broiu hitis with 01
without emphysema
(A) Bioncho- pneumonia, acute and
clu omc pleui o-pneumoma
(c) Chronic pleuns^ and cmpycnu
2 Obstruction, compression oi stenosis ol
bronchial tubes
(a) Obstruction by foieign bodies in the
bionc hi
(It) Compulsion b> .inourysm, hydatid,
malignant, glandular, or congenital
tumours (ey dermoid cysts)
(<) Stenosis as a result of syphilitic oi
other ulc oration, with consequent
stricture
3 ( 1hromc lung diseases (tubercle, cancer, etc- )
producing secondary bronchicctases, partly by
inflammatory piocess, paitly by compression
In some cases, however, no pievious history
of disease can be traced, and it has been sug-
gested that some congenital weakness of the
bronchial wall 01 deficient elasticity of lung has
existed
Much discussion has taken place upon the
mechanical cause of dilatation ot bronchi, and
without entering fully into the many theories
propounded, it may be taken for certain that
two general conditions are usually present —
BRONCHI, D1SKAHKR OF— BRONCH1KCTAS1S
27
1 Some weakening of the biunchml wall,
either congenital 01 more commonly of inflam-
matory origin
2 Some alteration in the normal condition*
of pleasure cithci \vithm 01 without the tube
fNDUCTNfi CAM —There is no doubt the
forced cjipiratwy r/otts associated \\ith cough-
ing are an important f.utoi in bringing about
the yielding of an already weakened Avail, though
it is impossible- to eliminate the effects ot dyspiwa
with UK i eased / w s/>t / atot y eiffot t The a< ciniii ila-
tion of secretion combined with the effects oi
gravitation doubtless ha\e then due si i die in
some cases
Mm bid Antitomy ami /Jitt/io/o<jy — The leading
features will be leadily appreciated by ieleieii(c
to the points indicated undei Ktiology Thus
the .ippeai. uu es vaiy with the cause, the dura-
tion, and the piesence of c oinpheations (pyaemia,
haemorrhage, etc ) Two genei.il foims aie recog-
nised (1) the it/lnulntal tn fun farm , (2) ike
ylolniltit <n \d< minted fnnn The bionchial walls
may be attenuated and atiophied, and the sur-
loundmg lung tissue' laiehed en e»mph \sema-
tons Mene coininoiily the walls aie maikedly
thickened, the peiibioiuhi.il tissue indurated,
the surrounding connective' tissue blunting a
tine interstitial and retic ular tirihosis, while
the inter veiling aheoh contain (.itaiihal pro-
ducts, which latci become organised The
c'hionic pneumonia thus induced is secondary
to the aft ec lion ot the biomhus In othci cases
the lung consolidation is piimaiy, and the* bion-
elnoetasis M'coiiflaiy Thus .1 twofold mdiiia-
tion of lung tissue occurs, sometimes confined to
the neighbemi hood of the dilated biomhusand
piesentmg irregular patches of consolidation,
at others spieadini; to the entire lobe In at ute
bronchiectasis the whole* lunu: mat> be riddleel
with cavities This is \\ell Men in childien,
when the lung is often sponge-like and honev-
cornbed In the1 fusifoim \aiiet\ long cavities
aie found, eithei radiating from the root of the
lung to the penpheiy, 01 tonhned to one 01
both bases In the sacculai foim the ca\itv is
usually banal, and it may be deep-seated en
superficial, containing very offensive, purulent
secretion In rare* cases the dilatation is apical,
and is thus usually associated with tubciculous
disease Occasionally a bionchiectatic cavitv
may closely simulate a phthisical one, but the
two can be differentiated by the piesence of the
basement membrane in the former The othei
viscera — heart, livei, hi am, kidne}s, etc --may
show secondaiy changes which are, ho\\evei, not
characteristic of this condition Thus we may
find any or all of the pathologic,»l appearances
of pyaemia, acute or chiomc Hemorrhages of
setous membranes, acute pleurisy or pencaiditis,
e»mpyeina, and mctastatic abscesses of biain 01
other distant paits are not uncommon
CHARACTER ot THE tifCRhiioj AND /?KOAU//I/
CoNfSNTS — On standing the secretion forms two
layers, an uppei frothy, yellowish or brown in
coloui, and a lowei consisting of purulent and
solid matter The odoin is extremely offensive,
and must be smelt to be appieciated Peecal is
the teim that most neaily descnbes it, but a
smell is difficult to define The solid inattci
consists of pus-cells, granulai niattci, and micro-
oig.imsms <!i}stals .ire sonu'timcs found of
leucin, ty rosin, cholesteim, and fatty acids with
man} oil-erlnbules Post-mortem, the dilated
tnomhi aie often found to be filled with pulta-
, ccous, e aseous looking matenal (vr "Kxpectoia-
I tifin ' ) •
CllNK 4L l'Hh&nMh\ t — ACUIK IJltONC IllKCIAblh
i 01 luonehiolectasis is usually a disease* of chil-
I dien Its sMiiptoms cannot be distinguished
| during hti ficjm thcjse of the capillaiy hionchitis
I with which it is associated
('ititoMr HRONCHIKC TASTS in a dise.isc* of chil-
dien 01 oi c>>uh 01 middle life, occumng moic
| hequently in men than in women When
se-e-ondarv to phthisis, cancel, en obstruction of
bionchi fiom an\ cause, it may O«MH in either
1 sex 01 at an} age-
(lylindrmil /jtoHt/tuifaMv is onlv to be diffei-
• enti.ited iiom the chionu Inonchitis 01 othei
] disease of which it foims «i pait b\ the excessive
1 bionchial hecietion, oceasioinlh b) fcrtoi of the
I cough 01 evpectoiation (thou&rh this is by no
me.ins const.mt), and b\ the- eulaigc'ine^nt or
clubbing of the tciium.il ph.ilangcs of fmgeic.
and toes, which is iif(]iic»iitly but not m\aii.ibly
! seen
I The characleiistic symptoms of the disease'
aiv moi o commonly obsi»i\ed in the \acvulated
hionchitcta^i^ loss often in the tylindric.il
(1ough is a piominent sMiiptom, and expectoia-
tiou with cxcc'ssne secre'tion ot an extiemely
oih'iisive and fa-tid cxloui
The couirh is iioejuentlv intermittent in chai-
actei and occuis m Molent paioxysms, somewhat
icscmbhiig whoo])ing-cough, and terminating in
the1 expulsion of a Luge quantity of mucus 01
nine opus piesentmg the chaiattenstic features
desciibcd Sometimes one fit of coughing, 01
pei haps two, occur dining the twenty-four hours,
often induced by change of posture (such as
lining fiom bed, stooping, l}ing down) It seems
piobable that the icason for the paio\}smal
natmc oi the cough and laige expulsion of
bronchial secretion is due, in the few cases in
which it is present, to the mechanical position
of the ta\ity 01 caMties, which, when tilled be-
yond a ce-rtain point, oveiilow on the least change
of position into the neighbouring undilatcd tube,
and set up an irritable spasm which leads to
violent cxpnatoiy effoits and subsequent expul-
sion of the contents
The sacculated tubes being thus emptied
entirely or partially, the patient may be free
fiom cough foi the* rest of the day and com-
paratively cornfoi table In other <«ises the
cough does not exhibit this paroxysmal nature,
BRONCHI, DISEASES OF— BRONCHIECTASIS
but is frequent, though still accompanied by
excessive and often offensive expectoration In
children the attack is often mistaken for vomit
ing. In reality a Hhght cough is followed by
retching and the sudden expulsion, not of vomit*
but of foetid mucus, sometimes exceeding half a
pint in amount J/ipmojrfyut is not at all un-
common, but except in Lite stages oi the disease
w rarely excessive The tttnpnatute oi the
patient is not raised unless the disease is asso-
ciated with bronchitis oi cataiih A irequcnt?
though not imauable featiue is the e/ublum/ oi
the distal phalanges oi finger s»and toes In
rare cases othei joints shaie in the enlargement
(see "OsteoArthropathy, Pulmonaiy ")
Nutiition is oiten well maintained, .uid the
strength and appetite good In latei stages
there m.iy be wasting, excessive djspncca, an
oiexia, 01 alimentarv tioubles None of the
above symptoms aie constant There m 13 be
little or no cough or expectoration Fcrtor oi e\-
pectoiation, cough, 01 bieath may be present 01
absent Clubbing cannot be leg.uded as patho-
gnomonic of the affection, though it is commonly
present In the Liter stages oi the disease
grave symptoms ,ire oiten associated, due to
catarrh 01 bioneho pneumonia, oi to ulceration
of bronchial tubes In the latter ease acute
septicaemia oi one, oi the many manifestations of
pyaemia may ensue Death may occur itom- -
(1) Acute bronehitis 01 brom ho-pneumonia
(2) Caidiac failure
(3) Exhaustion often induced by vomiting 01
othei alimentai y affections
!4) Amyloid disease and its accompaniments
5) Homiouhagc irom ulceiation into or
aneuiysm ot pulmonaiy vessels
(6) Acute 01 chiomc pucmia with milamma-
tory or suppuiative affections oi scums mem-
branes and niot.ista.tu abscesses, of winch the
most frequently recorded aiu abscesses of biam
Pu\ s/r AL »SVft »vs — Theio aic no pathognomomc
signs by which we can distinguish dilated
bronchi
It will be lememheied that in the acute
cases in children and in some < hrouic cases oi
cylindrical bronchiectascs, the signs aie those
of the associated bi ondatra only Foi the sake
of simplicity the physical signs may be descnbcd
under the follow ing heads —
1 Where the thveaw is nmsked by tin deep
position of t/ie Dilated litonthi ot by Einjthy^ema,
a tut uiiatrompa tued by stu round nifj Pneumonia
-The chest maj be lesonant oi hyper-iesonant
(m the case of emphysema) If the cavity
approaches the pleniral surface there is Skodaic
lesonance 01 absolute dulness, according as the
bronchial dilatation is filled \vith fluid societion
or not In the ioimei case bieath-sounds .it
the base oi basen (which .ire usually affected)
are absent or feeble, and the voice-resonance
diminished When the dilatation is empty, the
respiratory murmut becomes broncho-cavernous,
01 cavernous with marked pectonloquy This
variability m the physical signs is important
and will be lefeued to later
In the cases of deeply seated dilatations it is
not uncommon to find that resonance, vocal
fiemitus, voice sounds, and lespnatoiy murmur
do not depart fiom the noimal, 01 perhaps the
bieath-sounds are somewhat haishei than usual
Ad\entitious sounds may 01 may not bo present
When piescnt they vaiy tiom the small bronchitic
uepitatum to the Luge bubbling rale In this
and the next group oi cases, however, a marked
featuie may bo the extraordinary vanety of size
and sound of rale When a cavity is superficial,
bubbles and lales oi every si/e, squeaking and
" c io<ikmg " sounds, 01 merely sibilant or sonorous
diy sounds may be present The term " croak "
applied by Ew.nt well defines the c haracteiiHtic
quality ot the sound
2 ('rtsfs wltne tht Dilatation of Jfronchi i*
asforfofa/ with a vmnultuy (Consolidation o1
Lnrnf — Heie the signs of consolidation, either
patchy oi conhned to one or both baseis, .ire
supci added Dulness to percussion, diminished
or increased \otal vibration and resonance are
present, \aiyniig with the condition of the
pleura and w ith the depth ot the dilated bronc bus
When the case is well marked a feature is the
variation m the degrees oi increased voice-
lesonance as the stethosc ope is passed from one
spot to .mother .it the base In a tuberculous
cavity near the suriace there is fiequently found
a pe( tonloquy oi iairly uniioim character and
intensity over the whole surface1 of the cavity
It is not so wheic a series oi bronchicctatic
cavities occur nt various dintances from the
pleural mm face IVctoriloqny oi varying degree
of pitch and loudness is heard at different spots
on the chest-wall
Further, as in the* fust class oi cases, the
physical signs vary from time to time with the
full or empty state ot the bronchi.il cavity,
provided it is neai the surface Again, rales
j may be absent or numerous, and those that are
considered by some authorities to be peculiarly
characteristic oi the disease are sometimes
present, especially the "eioak" previously re
fencd to (described under different names by
various authors), and a sound known as the
" veiled pufl " oi Skoda, heard in rare' cases at
the end of inspiration It cannot be positively
athnned that these two sounds are never heard
in othei pulmonaiy diseases, but it is certain
that they aic more often associated with
bioncbiectasis
'J C'aws in which the (Consolidation or other
Disease 0} Lumj ttjnimmy, and the Dilatation
of £1 one/it a secondaty if suit — Space will not
allow a detailed description, which would indeed
be an account of the physical signs of condensa
tiou or fihrosis of lung due to an old pleurisy
01 empjerna, a chronic pneumonia, tubeiculous
hbtosis, or any mdurativc pulmonary disease,
BRONCHI, DISEASES OF— BRONCHI ECTASIS
29
or, again, of the Higns of obstruction of bionchiu
or of some tumours, malignant or otheiwisc,
producing compression
Retraction of the side and displacement of the
heart are usually the result of a compacting
fibrosis or of ,ui old pleurisy, and aie not found
so frequently in the second gioup, where the
organising pneumonia is sec ondai y to the dilata-
tion of hionchi When the disease is conijned
to one or lioth apices ot the lungs the ease is
usually a tubeiculous one, though I his is not
an imaiiahlc iiile
DjifiNos/s — (a) from TulHitutouv IJi \ni\e of
LUIUJV — In the eaily st.iges tlie compaiatne
well-being of the patient, the absence of wasting
find of pytcxia, and the common assoc lation oi
clul)l>ing of fingeis (moie i.ue in tubei( ulosis)
serve to distinguish the <ase horn one of tubei
culous disease In phthisis a basic dise.ise,
moieovei, is ot extieme laiitv, unless the apex
has been primanh aitec ted Tubei culous cases,
however, do oecui \\ilh hhioid eonsohdation of
one base These aie usiialh of plcuntic 0111*111,
01 aie found in laie cases ot senile tubeic ulosis
The absenee of tubcnle bacilli is to be
assumed It must not be foigottcn, hnmoei,
that bionchial dilatation \\ith its (haiacteiistic
symptoms is occasionally an .ic compammeiit of
tuberculous disease, espec ully in those foims
wheie thoie is much inclui.ition The diagnosis
IH moie difhuilt \\hen then1 is bionclnec tasis
with ihiomc pneumonia oi the uppei lobe,
especially it h.emoptvsis be ilso piesent In
such cases the1 physical sign (upon \\hich stiess
has been hud) of the -\ai i.ibihtvot voici'-iLsonancc ,
and even of iespnatoi\ nun mm in ditlcienl
situations at the ape\, becomes of nu]xn tance
The changes due to the emptying and letilhng
of a ca\ity aie sometimes iound in a basic tubei
c ulous excavation, but fai moieolten in bionchi-
ectfiNiH rPhesc signs aie less likely tooccui .it
the apex of the lung
(ft) The divhanfe of a litcahwd ot vnnll hnw
emjtycHiu into a bicmchus with the toimation of
a peimanent SIIIUH is to be distinguished iiom
bionchiec tasis by the histoiv of the diseise, and
usually by the absence of fu'tor ol the muco-
purulent 01 pm ulent disc hamc The diagnosis
is not always easy, because in an old dischaiguitf
emp^ema the lingers and toes .no often extremely
clubbed, the dischaige is mteimittent and occa-
sionally blood-stained and fu?tid The fcrtoi ol
expectoiation is usually a sign that more than
a mere sums is piesent, and that piobably as a
result of the plcui isy and consequent cm hosis
of lung some of the ucigh homing hionchi have
become dilated
(c) Chronic /ironchilis — Asv\c have pie\iously
stated, it is often impossible to diagnose dilated
bronchi in a case of chionic bronchitis, though
it may be conjectured that the condition is
present if the sputum becomes foetid and the
fingers clubbed Most authors describe a form
of bionchitis with offensive sputum under the
name of foetid bronchitis 01 bronchorrhoja. The
writet is of opinion that this disease is a rujth,
and th.it tutor of the bionehitic sputum in
cases of chicmic bionchitis means nothing more
than that some of the hionchi are the subjects
of fusiform dilatation, and that owing to the
accumulation ot seciction and consequent de-
composition the sputum becomes otlcnsivo
When the hngeis aie not clubbed, tare must be
'taken not to confound fcrtor of bieath, cough,
or sputum \\ith that due to othei causes
Phar^ngeal luucu^ is sometimes excessive and
of ei-tiemely offensive odoin, but the discharge
is usually in the eaily moinmg ()7<ena and
the fu'tor trom canous teeth and the offensive
bieath horn constipation \uth disturbed livei
must all be eliminated
(<l) (ranyi ene and Al*< t sj» of Lun<f — (rtuiffrf ne
is an ai ute ind gnu e condition, and could only
be confounded with the l.itci and ulceiative
stages oi bionehial dilatation As a rule1, the
histoix aids the diagnosis The gangrenous
odour is usually distmc t and chataeteiistic, but
may be confused \vith that ot bronchieetasis
Some aid is also to be obtained from an examina-
tion ot the- sputum In gangrene- theic is more
destiuction ot tissue, and elastic fibres are
fiequcntly found, \\heteas the expectoiation
iirnii a inonchiectatic cavit) raiely contains
I them li gcingiene is associates! with tuber-
j c ulosis, tubei ele bacilli will also be piesent As
in the case of ganufiene, the foimation of a
jniluxtnm i/uh\t ess is sudden in its onset Whether
.i sequela of pneumonia 01 a lesult oi pulmonary
embolus, the1 disease is acute, and usually an
evacuation of pus is followed by a quies<e»me of
symptoms
Cases, howe\ei, occur of a b«isie pulmonary
abscess in which la tor of expeetoiation, inter-
mittent cough, and chschaiire ot pus and club-
bing of hngeis aie pi encnt They aie extiemely
difficult to diagnose tiom a sac ciliated bronchi-
cctasis Tlie tcvtoi is not so pionounced as in
gangiene Seveial case's have bc*cn icc-oided in
which opci.ituc pioceduie has lesulted in com-
plete cine V small localised emp^ema dis-
ch.numg thiough the- lung, 01 a sub-pleural
chionic abscess, ma\ easily be c out ounded vv ith a
single sac dilated dilatation of a bionchial tube
Phw,\o^ — Bionchiectasis is usually an ex-
tremely chionic disease In children the acute
cases associated with capillaiy bionchitis rarely
recovci The condition of the heait and cir-
culation (espec wily light heait) is an impoitant
! element in prognosis The onset of pytemia,
acute 01 chiomc, profuse haemoptysis, or cerebral
symptoms arc of grave significance, and usually
piccede a fatal tei initiation In addition to the
many complications of the disease already re-
feried to, death may result from exhaustion
TMAFMRNI — General Consuleiatww — Atten-
tion must be paid to the nutrition and strength
30
BRONCHI, DISEASES OF -BRONCHIECTASIS
of the patient A dry, warm, or equable
climate, and remedies that improve the appetite
and nutrition, aie advisable Amongst such
remedies may ho included cod-liver oil and malt
extracts, the hypophosphitcs and glyceiophos-
phates, with or without one of the following
tonics quinine, 11011, orbtiychmnc Two dings
appear to act in a twofold manner Brn/ol in
five- to tcn-minini doses in ,i flavoured emulsion,
and creasote in capsules ol one, two, 01 mote
minims, not only mcic.isc appetite and impicne*
the digestion, but piohibly act as antiseptics
They me both e.isih toler.ited nftci the hibt
few doseb An} or all of these, especially if
combined with the influence of <i diy, puie air,
increase the vigoui and lecupeiative powci ol
the patient, and piohabh lessen the tendency
to eatairh
Complications Jlionthiti* and tattu thai tijJM-
tiontt of the lungs must be treated on general
principles dntdiae failure \\ill need the ad-
mniibtiation of digitals oi canliae tonics Uaie
should be taken in the case ol systemic engoigo-
ment to encourage the action of the h\er secie-
tion by admtnistiation ol small doses of mcicuiy
or cholagogne purgatives, .uid to piomoie
diuresis Alimentaty tiouhle\ ,ire to be dealt
with by sedative tieatnient 01 digestive tonics,
with bland, uniiiitating nourishment If
/icemoptysik OUMUS, absolute lest in the recum-
bent position should be pi escribed, unless the
symptom is veiy slight In <asc oi profuse
haemorrhage, morphia may be gi v en \\ ith c <iution, j
combined with lemcdies that diminish arterial i
tension, while the amount of fluid in the diet |
must be diminished i
Special Tt eat went Tho object is to dimmish
bronchial nutation and inflammation and to
promote antisepsis
Guaia<ol is of special \aluc when giv»in in
doses of .3 to 5 grams sevei.il times a da} in
capsules or cachets Tciebene (5 giains in
capsules), oil of tuipentine (10 to 20 minims
with muc il.igc in an emulsion), ben/om (10 to
20 minims of the compound tincture), or bcnzoic
acid (5 grams), ammoniacum 01 guaiaLiim (half
to one ounce of the mistui a ammoniac 1 01 rmstm.i
guaiaci) — all these aio found to be of seivice in
diminishing chrome catarth ,ind in lessening
the bronchoirhou oi excessive scciction
Many of these remedies act dnectly through
the blood, and some, like guaiacol, aie probably
eliminated thiough the respnatoiy mucous mem-
brane If l.uge c«ivities aie present in which
secretion actumulntcs and decomposes, it is ol
the utmost nnpoitance that all the means .it
our disposal should be adopted to empty thebo
cavities as frequently as possible Without this
the value of astringent treatment is diminished,
and all the subsequent measures th.it aie now
to be described will be of little value
Methods of emptying Jtronchiectatoc Cavities —
Change of posture will otten produce violent
cough with the expulsion of a large amount of
expectoration In some cases the act of lying
do\M), stooping, 01 even leaning out of bed is
sufficient The occasional paroxysmal attacks
aie lather to be encouraged than not
The Continuous Inhalation of Cicawte — The
continuous treatment by the inhalation of ciea-
sote bis found great tavoui, and is probabh
more successful than any othei method in Iwtd
cases The patient should be placed in a special
loom oi chambei, in which an ounce or two of
oidinary commercial cieasote is vaporised on a
small metal bath heated b\ a spnit lamp The
patient's e\es arc coveted, and the nos tills
plugged with cotton -wool He inhales the
dense fumes ot cieasote vajwui foi a quartei
of <in hour to twenty minutes, .it first eveiy
other da} Ultimately he should l>e subjected
to it foi one* hour to one horn and a halt daily
by blow inciements m the length of treatment
Tolerance is soon established, and in many cases
the lehef is consideiable Violent cough and
men e 01 less complete empty mi> of the cavities
is the1 result Probably some absoiption of the
diug and possibl} a ceitain amount of local
efler t aie piodutcd, though this is doubtful
Otc.isionalK the anicliomtion is i.ipid and
decided, but in man} CIM>S the lesult of months
of treatment is onlv a diminution of expectoia-
tion, and especially of the fu'toi ()c casionall}
brilliant lesults have been produced It may be
asserted th.it hettei lesults have heen obtained
at the biompton Hospital fiom the prolonged
use ol cicasoto inhalation than from any other
toim ol treatment
Provided the dilated bronchi can be partially
or wholly emptied, othei methods ot tieatnient
which aie believed to h.i\e a local effect ma}
be valuable These aie (I) Mont Inhalation*
''icasote, tuipentine, carbolic and, 01 compound
tincture of ben/om .ue mixed with hot water at
a temperature oi 140° in an inhalei It is well
known that though these lemedies aie deepl}
inhaled thev do not loach fai down the tiachea
The plan ol tieatnient is well lecogmsed, but is
not of permanent value
(2) JntHt Intytujeal fnj«.ttom> — A 2 pei cent
solution of guaiacol 01 of eie.isote in menthol
dud olive oil injected daily oi ever} second day
is beneficial in some cases
(3) Treatment by Diiiq* whuh jiroitiote Anti
<*/»*» i awl dimmish Fwtoi — Guaiacol and crea-
sote have already been mentioned Garlic, 1 to
3 grams in cachet, 01 1 to 4 dims ot the syrup,
either alone with equal quantity ot syiup of tolu,
01 in combination with creasote and syrupus
picis liquid.!), has also been recommended The
disagieeable cxlour following its use is a dis
advantage
Operative ptocedwe* have not been attended
by good lesults on the whole The opening
and drainage of cavities at the base of the lung
have been frequently tried, usually when it wan
BRONCHI, DISEASES OF— BRONCHIECTASIS
31
thought that theie was a single cavity The
results are not often encouraging, because fre-
quently multiple cavities have l>een found where i
one has been diagnosed There is some danger !
of septic absorption into the Hiiiioundnig tissues |
and the edges ot the wound «uul MIUIH foimed, j
owing to the putnd chaiattcr ol the e\,uuntod I
.secretion j
Indications ioi op(>i,ttion aie found in tlu
following si^ns — (1) Theie must b- eudeme
of a unqlr ca\it\ (2) (Jiven a single cavity,
Ingh fevci and signs ot ulceiation of biomln o.
of putrid absoiption completely justify un opeia- j
tion, consisting oi lesection oi poition of one or '
two ribs and the diainage of the c.ivitv (Join- I
plete recover\ has sometimes icsnlted
Bronchiectasis. r/*sM//i« BIU.MUI ,
PULSE (?T? rnewnoma), HICKKTH (Complication*) ,
TYPHOID KE\ER (Complieatum* and He
.- Ha>morrhage trom
Branch iocrisis. ,sv< T\m- I>OKS\US
(Hronc/nal dtiw) I
Bronchlolectasis. N« BROVMU, ;
BRONTHIECIAMS j
BrOnchiOlitlS. -W Luv,, Ti HBRCL
LOSIH OK (PatJioloyHot Anatomy) TIIHKWTLOM
(Morlml Anatomy, /v/w/s)
Bronchiospasm. *Vf \-IHM \ (A'atm
and
Bronchitis. r/f/f ^j»n, BHOM HI, BRON-
CHITIS
Bronchitis, Capillary. .svr I'NBI-
MO\IA, CLINICAL (CWi/i/irti flows)
BronchOCCle. X', Timtnm <JLAM>,
. A loncietion 01 call arc
ous torm.it ion in i bioiuhial gland oi tube
y. The sound ot the
volte heaid b^ means oi the strthosiope plat til
over the coinse ot the ti.u hea and bionthi , also
the same sound heaid, .is a pathological condi-
tion, over lung tissue in a moibid (consolidated)
state *SVc (JuKsr, Ci IMCAI. lN\hsrin,A'iio> OP
(Auscultation) PNKUMOM \, Ci IMPAI (Pht/wrtl
BronchOphthlSiS. -Puimonao phtlu
818 comment ing in ulceiation of the smallei
bronchi
.— The association ot
bronchitis with pleuiwy See IJRONrui. BRON-
CHITIS , PLEURA, DISKAHKS OF
Bronchopneumonia. — iniiamma-
tion of the lungs originating in the smaller
bronchi , catarrlial pneumonia tice ALCOHOL
(Clinical Use* of), BRONCHI, BRONCHITIS , BURNS
AND SCALDS (Respiratory Complication*) , PNRU
MONIA, BACTBUIOIXJUY , PNEUMONIA, CLINICAL .
the bionchi
BronchorrhOSa. — < 'hiomc bronchial
<at.uih \sith e\eessi\e secretion. »S',f BHOXCIH,
BRONCHI ris (Chnunl }rftnefi">) , BRONPIII, Buos-
«HiF(,TA,sis, TimtoiD (ji<AM>, MMIICAI (Etnph-
,f halm n (r(n(H', /{eyHHitni i/ Xi/ifi-M)
BrOnChOSCOpy.— The USP ot the 1 lon-
( hoscope foi tne inspection ot the mteiioi of the
biMiK-hi, for the detection and lernoval of foreign
bodie^ theiehom , jt may be passed thiough the
mouth .u id Lirvnx <» (bettei) thiuiigh a tiacheo-
toniy wound , it*, use has been lecomniended
.ind poilivttd bv Kilhan
BronchotOme. An nibtiument em-
ployed in pot-t-moitem examinations lot laying
open the bionchial tubes .
BrOnchotOmy. An optiation st)iue-
tunes pei ion nod for the ienio\al of foieign bodiew
fioin the laige bioiidu, in postciior bioneho-
tomy, icse(tion oi some of the libs between the
s<<ipiil\ 'ii id tht1 spinal column is eaiued out
Broncho-vesicular Breathing.
— The t>pe of bieath sound noimally heard in
the mtcisiapular leirion and o\ei the uianubnum
sterni , heaid o\ei othei ])aits ol the lung it may
indicate earl\ tubeiculu disease See CHEST,
CFIMCM INM-SIK.\IIOV OT
Bronzing of Skin. *« ADRENAL
(JLAM)s, Ani>ISi)N's I>1<«FASR , Dl\B*.lEs MELLITUh
(Ni/mjitom*, The Skin) , NEW-HORN INPANI
( \Viiulel\ /hwte, lii<m-ul HcLinatin H Dtwaie) ,
i(«.> (Lomt f/'Attiir/rs, Awlominnl Wall), SKIN,
Pl(rMEM\li\ An-Fi 1IONS Op (AtttHH. /itOiUlHfft
<tc), Tn>i«)M) (Ji \M>, MKDICAI (Eiophthalmit
(Inline I*H/nn Htatmn)
BrOOm TOPS. - Bioom tops (& opart i
Cai'umtna) aie used as a diutetic medicine, in
association with other dings, in dropsical con-
ditions, but not in at ute nepbi itis , the} t ontam
.1 diuietic piuuiple (tico/xn DI), and an alkaloid
(^jtattfini1) , the ofhual prep<u<itions arc the
Intu^um tfcojnru (dose, 1 to 2 ti 07 ) and the
tiurru\ Sio/Miift (d«>se, 1 to ii H di )
Brophy's Operation. —A modifica-
tion of the pl.istu opciation toi the cure of cleit
palate find haie-lip introduced bj Tinman W
Biophy , it consists in e.irl} opeiation (within
the first three months of life), in collecting fiist
the clctt in the palate, and in scpaiating the
mucous membi.me ovei each malar process (so
as to permit appioxiuiation)
Broth,
BOUILLON , INVALID FKKUINU
32
BROTH
(Food in Convalescence) , POST-MORTEM METHODS
(Cultivation Media, Bee/ Broth)
BrOUSSalSlsm.—The doc time of patho-
logy and therapeutics mtioduccd by Fianeois
Joseph Victor Bioussais (bom 177'J, diod 1838) ,
in it gieat stress is laid upon m liability, <ind
especially that of the imuous mcmhianc of the
digestne tract Her BRUNOMAN Si si EM
BrOW Agfue.--Fiontal (tiigenunal) nour-,
algia, especially \\hen iu.il.uial S<e Ntit\fcs,
NEUKALC.IA t
Cases. Xw LABOUR, DIAGNOSIS
AND MECHANISM (lliow ruwntdtton*) , LABOUR,
M AN A( , E MENT ( Jit OH')
BrOWn Atrophy. — A degenerative
change in the nrvcx.irdium, met \vith in chronic
vahul.ir disease, et( See HEARI, M\<X'\UL>IUM
ANP ENDOCARDIUM (Motbid Pioccw>, Atrophy)
Brown Induration. — A state of
passive, mechanical congestion of the lungs,
met with commonly in heirt disease, and also
from the piessure of tumours, the lungs aie
large, "iusset-bio\\n" in (oloui, and show an
increase in the conncctm* tissue \ihich they
contain tfee LuNds, VASCULAR DISORDERS
(Ai«si w //?/jiei win in )
Brown ism. AV< BRUNOMAN SISIKM
Brown • Sequard's Epilepsy.—
The convulsne phenomena which follow ccitain
expei imental lesions, such as hcimscction of the
spinal <.oid, division of the .sciatic nei\e, etc
See a/so KPILEPSY (Etiology)
Brown -Sequard's Paralysis.
The synch ome due to uiiilater.il lesions ot the
spin.il coid (e <f m syphilis, tumoins, h.umoi-
rhagcs, etc ), uith paralysis on the same side as
the lesion, and cutaneous anaesthesia on the oppo-
site side tiee SPINAL CORD, MEDICAL (Jliown~
Bruch, Membrane of.
AND CILIARY BOD\ (Anatomy)
n alkaloid dcmcd from the
noh nun wmieti, acting as a local anesthetic
.SVc ALKALOIDS , Nu\ VoMir\
Bruises. «SVr MFIHPIMC, KORENSIC (Jfnuh
«/ Wounds) , KNEE- JOINT, INJURIES OF (limi\ei>)
Bruit. — A name given to Aaiums sounds
(murmuis) heaid on auscultation ovei the heait,
great vessels, lungs, u'sophagUH (stuctiuc), and
uterus (pregnant or with hbioid tumours) The
ltruit d'awtun is the metallic echoing sound
heard in pncumothoi.ix , the btmt de cutr neuf
is the "new le.ither" eieaking mm mm heard
in fibimous pericarditis , the bruit de duable ib
the "humming- top" murmm or venoiiH hum
heard in ana-ima and exophthalmic goitre , the
bruit de drapeau is a dry rale due to the vibra-
tion of bronchial casts in fibrmous bronchitis,
the t>ru>t de galop is a sign of muscle failure of
the heart, and consists of a triple rhythm ot the
caiduu sounds (double fiist sound and accentu-
ated second) , the Itruit de moulm is a splashing,
chuinmg sound mctuith in pncumopeiuardiuml,
the bruit de jtot feW, or ciackrd-pot sound, is
that heaid, on percussion, o\et large thin-walled
pulmonaiy cavities, and best with the mouth
open, .ind the bunt de vntflle is the common
"bellows minium " heaid in endo<aiditis, etc
Brunner's Glands.
glands of the duodenum discovered by Hiunnei
( 1 G53-1727), a Swiss anatomist tiee LNTEH TINES,
DISEASES 01 (AnatomictiJ and /*hywolof/ical (Ion-
t>iderationi>) , Tn^sioUMn1, DICLMION (Structure
of Alimenting Canal) , SioiiAt'ii AND DUODENUM,
DISEASES OF (Anatomy, tti )
Brunonlan System.— A theoiy of
medicine founded bj Di John Bio\\n 01 Bruno,
a Scots physuian (1735-S8), M cording to whom
physical hie and disease were due to a pctuhai
excitability (01 mutability), e\cessi\e excita-
bility prodiued sthenic diseases, and defective
led to asthemc ones It iv.ih opposed to the
practice of blood-letting
BrUSSa. AVf BALNKOI <*,\ (Tut ley)
BrygfmUS. — Chattel ing of the teeth
BryOCytlC. — A disease chaiactciiscd by
cell piolifciation is said to lie (» i/oi y( t< , eg
syphilis and cancel
Bryonia.- The loot oi Hn/oma all>a and
/{ dioira, (ontaining a glucoside 01 bittei
pnnciple (bi 3011111) , it is ottiu.il in the I'mted
States , it is used (i.uely now) as a hydragogue
cdth.utic and (exteinally) as .t vosnant the
Tinctura Hit/onto' is grven in doses «»t "2 to 10
fl dr
Buboes. *SW VENEREM I>isi<\sj (tfoft
Soiei, Complication*) *SVf aho GROIN, PI.AUUE,
RHFUMATISM, vSMN DISEASES, SYPHILIS, etc
Bubonic Plague. &e PLA<.UF
Bubonocele.- Any spelling in the in-
guinal legion, but more especial K a hernia
Xee HERNIA
BUCCO-. — As a prefix "huc<o-" signifies
" relating to the mouth," and is used m such
combinations as bucco-labial, >)ncco-pharyngeal,
etc
BuChU Folia.— The leaves oi the ttar-
osma betulina, the official preparations of which
are the Jnfusum Buchu (dose, 1 to 2 fl oz ) and
the Tinctura Buchu (dose, $ to 1 fl dr ) , it is
used as A mild diuretic and vehicle for other
IJUCHU FOLIA
diuretics in oatarrlml uttections ot the bladder
and in mm y tiact , it gi\cs A marked odour to
the mine (Note liiu hu is an indeclinable
wortl )
Buckthorn. <S't<? ('ASCAHA S\f.ii.u>\
Klephant-leg (liom<!i ftov,
augmentative particle, and it >'«)/*?/, the le«») >SW
Budd's Cirrhosis.— Pvsprptie (uon-
alcoliolu ) hepatic uuhosis >SV<? LUKK, DISLASK
OF (Pot tal Citifuwi)
B U do. »Vw Tn t R \Ph L i irs, 1 1 L \ 1 1 ii R*,s( ut i s
Buffy Coat.— In slow clottmo of the
blood (ft/ in fevcis) the led < ells ha\e time to
sink somewhat, IIMMIIU the uppci ]),nt oi tin
clot ot a palei coloui, the jiiey 01 "butty (oat ''
(frtntin/ Chntnilti1*)
Bug, Harvest. /fa SMNMV, I\SU<L,S
Buhl's Disease.— \< ute f,ui\ dcirenoi,.-
tion oi the new-boiu infant, with turmoil liases
in the heait, h\ei, and kidneys »Vif XLW-HOHN
IN FAX i (/J/vf/sf s, Jln/il\ fti^nsf)
Buist's Method of Artificial
Respiration. *svt Asrm \\\( R< wsr it<tii»n,
Bulam Fever, .sv ? Y* u < >w KF\ LU
Bulb. — With the miMiinii' of a somewhat
spheiic.d dil.itation this teim is widely used in
anatomy and physiology, t (/ han-btilb, bulb of
the uictlua, vaginal bulbs, end-bulbs, bulb of
the o\.uv, e^c, etc The bulb of the spinal
coid is the medulla oblon^ata Wet and dij
bulb theimometeis aie used in h\uiometi} *S'«r
MEI h<>Koi i M.I (J/v/toincft //)
Bulbar Paralysis. -A disease due to
an aflection of the neurones of the inotoi neives
ot the medulla oblong it.i , iilosso-labio-l.iiynj»eal
paiatysis »S/v PAH \i\sis (Ilulltnt Ptiialy\tt>) ,
Aunuom NKII\E AND LAinuiMii (JTnw Dent-
Atrophy in You in/ Ckilihtn) , S*HI\<.OM\M i \
Bulgaria. $«> RAIAFOUIM (Ttnkey,
Bulimia. — Inoidnutc oi \oiacious ap{w-
tifc, associated with huntness , bulmnasis tftt
Api'EriTE (Incteaw)
Bulla.— A bleb or bhstei .SVr> SKIX,
i «!• , LUMIOS^ , PEMI-HU.US, etc
Butler's Shield. >SW (OVIUNCHNA,
>ISBAHU( (I'umltnt Ojiht/tnluua, Tnntment)
voi. ii
Bullet Wounds. *<>< MTDICINK, K<m-
LNSH1 ( H'oMIK/s />«»«, />/«Iims) , Will MIS
( Vffmtfifs)
Bui piSS. — A pai.isitu skin disease of the
iiatuie of im^uoirn, Ofemiin^ in Niiata^ua,
and piobably identii.il with the disease (Jut nit
oi South Aineiica Xu Skis, r/.{\Mu s (Tm«t)
Bungrarus. *lt ,SN VK* u- IES
• Bun^e'S Law. - The fatt that a paiallel-
i-m exists between the a» lies ot the milk of the
molltei .inunal'and tin1 .isl'ts ot the ta'tus , it
does not hold with ui»Aid to the human tntiih
and human milk
Bunion. XivmrnuMim-s (//«///// r.rA///s)
BuphthalmUS. I.itoallv "o\-e}e" ,
is a l)ulur"".r oi piotiusion ol th»« whole eje,
with nuiiasc of tc nsion , it is known also as
UK i:alophlh ilmiis, (oniic 'int.il ^l.iiu om.i, and
h\dioplitlialniiis eoni>f nitus f it is due to a
maltot mation in the «-\e (a/ want of sepaiatiou
of the ins Mom the loinei in the lejrion of the
hirainnitmn ]x»(tiiiatiiin [ivr/r ILill int^ lie's Ante-
tuit'tf 7V////0/OV//, \ol n 110, 1M04J)
Burdach's Column. .sv<> SPINAL
Conn (Ana(twiyt Awnd<n</ Tnn
Bu rd wan Fever. ^ f .M \L \ m \
Burgundy Pitch.— Ti\ Buiuundua, 01
the lesm fiom the hpiiue in, is used as a basih
foi pl.isteis, it (ontanis pnnaiie .u id, a volatile
oil, etc , the olhtial piepaiation i* Emjt/attivm
J'u it
Bu rial- Places. ^ <i^<> CM>\\\\ u A —
The disposal oi the dead commonh takes the
f 01 m oi eaith-to-eaith buiial, foi ciem.it ion m
not yet (ommonlv pi.u tisetl and \ault buiial is
much lestiitted IJuiial - places 01 cemeteries
should be situated in the subuibs oi lai^e towns,
and should, it the same time, be easy of a«ess
Old (euutciies in the teutic oi a town should
be closed, tlie\ may be comeiled into open
spues, but must not IM» built upon (sa\e foi the
pui|M»ses of enlai^imx a place of \\oiship) A
day soil, i chalk} one, and a loose ^iiavel one
.ue all unsiut ible foi a cemeteiy, the best kind
of e.u th bemu a di^ loam The di .image of the
sin face soil should be thoiouuji , theie should
be no wells in tommon use in the neighbourhood
of thcMomcteiy Tiees and sluubs should be
])lanted One-iouith to one-hali atic pei thou-
sand pel sons of the population is the spat e \\lnch
ouiiht to be set aside in towns foi the puifx)seH
oi buiial Individual m.ues should not be
moie than ei«:ht teet deep, foi dissolution of the
b<Ml\ takes pl.ue moic innckly near the surface
of the ^lound , at the same time, four feet ot
e.uth should always co^er an adult borly, and
3
34
BURIAL-PLACES
three feet that of a child under twelve yeais
Wicker-work or light wooden coffins are bcttei
than heavy wooden or leaden ones, for they
permit a more lapid dissolution of the body
A foot of earth must separate two eoihns in one
grave, and no mm ailed i?iaveshall he icopened
within fourteen ycais after the bunal of a
person above twohe years of age 01 within eight
years after the burul of ,i child under twelve
years of age, except to biuy anothei membei oi
the b,imo family Snuc it is undesnable« and
may be dangeious toi de.ul bodies to lemam
awaiting biiri.il in the hunn-ioolns of the p>oi,
it is desnable that all towns should be pioudcd
with Afortnarn">
The Acts ot Paihameut iegaidin« buiial-
places (for England, Wales, and London) are
the Buiial Act (1H33), the Public Health Act
(1875), the Public Health (Interment) Act
(1879), and the Disused Bunal (Jiounds Act I
(1884) For Scotland theie aic the Hunal '
Ground (Scotland) Act (18«r>), and the Public '
Health (Scotland) Act (1 807)
If vaults aie used at all they must be cMiclosed ,
with walls of brick oi stone solidly put togethei ,
with good mental 01 cement, they must not be
distmbed VtUilthiin.il, how OUT, is not to be '
reeommended A gia\e whn-h is walled with |
buck 01 stone woik is ie<* aided as a wult
Burking1. The muidermg (usually by ,
sruothoi ing) ot individuals m oidei to sell then j
bodies for pin poses of dissectmn The n urn1 j
took its ongui m connection with the notoii- i
ous Burke and ll.uu case, in the West Poit
muidcieis of J'Minburgh, in 1828 I
Burmese Ringworm. -Tiopuai i
nngwoim 01 Dhobie's itch iSVf Ski\ DISF \si-s
OF THE Tuoi'ics (Cauwd hy VftjetaJMe Paravte*) |
Burnett's Fluid.-— A solution of /me !
chloride, hawug a sp <ji ol "1 0, iivd as .1 j
dome-tic antiseptic-
Burns and Scalds.
DEFINITIONS 31
CAUSES 34
RISKH 34
ChAHhlllCAIlON 3f)
CLINK AL FK \ri uiths 35
(jtneirtl Phenomtnti 35
Local PhenoMfHfi 35
PAIIIOIOM oi1 BURNS 36
Tun, \niFM1 37
MEDICO- LuiAl, Asi'hc is 30
See nho DEIORMIUKS (Club-Font, Acquit al),
E\bu\LL, IMUUIKS (ir (tty lit at) , CAXCIKENE
(fining, (JROIN (fn/utiei of, Ktnm>), MEPiriNE,
FORENSIU (/JK/ns), RADIUM, SKIN tiKuriMt,
TEMI'LIIATUIIK (DfJiTfWOH) , X-U\\M
THK teim Jiuitt is applied to the mjuiy lesult-
mg from the application oi diy heat to the
tissues of the txxiy , while the ddinage done by
moist heat IH usually spoken of as a ti<ald
The distinction IH ummpoi taut, as the essential
chaiacters of the lesions pioduccd by the two
foims of heat aio for all piactical purposes the
same , .ind conditions <ilmo»t identical frequently
result tiom the applu.ition ot such stiong
c.uistic substances as tinning nitric a< id, caustic
potash, intiatc of silvei, 01 aiscmcal paste
('AL *«y *» — Fire and steam pl.iv sue h an unpoit-
aut pait in eM)iyday lite and woik th.it the
accidents pioducmu bums and scaldsaic iniinito
m then \aiiety Amoiit; the commonest aie
the ignition of clothes, especially tho«e of
women and childien, the l)tiistmg ot p.irattm 01
othei lamps, the spilling of hot fluids, molten
metal, ot boiling oils, explosions oi g.is 01 gun-
powdei, and the escape of steim m boilei
explosions Sc\eie bums sometimes follow the
application oi \ciy hot poultices to joung and
debibtited childicui
Siuh substances as hot solids, molten metal,
and stioug caustics aic lot il in then ac tiou, and
pioduce bums whuh, although deep, aic limited
in extent Flames, exploding gases, and vapouis,
on the othei hand, occasion moie widespiead
injiii> to tissues, but the damauce is mmpaiatnelv
sii])c>iiuial Then nsk, ho\\e\ei, is a« entuateil
by the mh.ilation »>i poisonous tinnc's in solid
paitu Ic^s of cat bon and dust into the an -passages
and hint's
Si aids lesulting iiom Ixulinn w.ttei oi stc«ajn
aie l.^ss se\eie l«Kall> than those <aus(»d by
boiling oils or saline fluids , 1ml the inhala
tion erf steam into the aii-passiges mtiodiicts
addition il iisks in the- (oitn of (rdcin.i ulottidis,
bionchitis 01 bioncho pneiuuoni.i, compile .itions
which ma} also follow buriiH o^ the mouth 01
phaiynx lesulting horn dtmkiui> xny hot Hinds
01 caustic substances
Since- f In ttn tty has come to assume' such a
prominent pl.uo in indusln.il undertakings, a
distiiut ioim ot burning IMS been lee o^nise'd
Mt'ty .ind I)onhcmsc{uet-Lihoidc>]ie h.i\e studied
this vane tv ot bums, and ha\u iommUted the>
follow ing piopositienis ic'^aidinn them (I) The'}
may be superficial 01 deep, (2) they aie not
pamiul , ( J) they aie not accompanied by lev PI,
oi followed bj any constitutional distuibance ,
(1) be-mg ase'ptic the v do not tend to suppuiate,
and (5) thcx cicatnse qnii kl(> .md well
7?/sAs — The main fae tens upon wine h the iisk
of a bum depends aic — (1) Its ettftit It ban
been shown that bums implicating horn on<>-
h.ilf to two -thuds oi tho c»ntne surface ol
the body aie. almost im.ui.ihly fatal (2)
Its situation Jiums o\ei the serous caxities
of the body — abdomen, thoiax, 01 skull -
.u e, ctteru* jHnibm, much mote dangeious
than those on the limbs (3) The a</e of the
patient Although young childien succumb to
the shock of scvcic hums more readily than
adults, they appeal to withstand prolonged
BURNS AND SCALDS
35
suppuration bottei (4) The presence or absence
of Mp*s is a most important factor in regard to
prognosis
07/4ss7*7< 177/w OF /fwtvs — Tho classification
most geneially accepted is that of Dupuytren,
•which has foi its basw the deptli to w hich the
injury has ponetiated He distinguishes six
degiees — I Hjperajima 01 Kiythema , II
Vesi cation , 111 Paitial dostmeti.u of the
thickness of the tine skin, IV Distinction of
whole thickness of the true skin, V Charring
of muscles, and VI Chan ing ot bones
CuMrAL KLAiURhs or IJi IINS
(rFMHAi /•*;/* \»v; vi -Tln» seventy ot a bum
depends e hicily on tlie extent of sin lace impli-
cated, and to a les*- dogiee on the depth oi the
lesion The inttnsity ot the heat and the dui.i
tion of its application an* also impoi taiil iactoi.s
Almost .ill bums which aie it sulln lent
seventy to be bioiight i.ndei the notii «• <>t the
suigecni pifM.nl in point oi time thiee di<»tm< t
clinual stages — 1 The stauo ot fntnp\1inn nml
pntn , II the stage ot ft on 'iml ni1iammn1nm ,
and II F thestigeol Mijijmrtilwn
I «S*7 K.7 "7 r«T"\'.7 -J7"\ i\7>7*!7\- This stage
lasts .ibout ioitvemht hoius, dining which the
patient is in extiemo agom, and I ho whole aiea
imohcd in the injun is mteusc-K congested
and somewhat swollen The patient suHeis
irom a toim ot tiaumatu shock 01 lollipso,
til tiilnit.ihlo to icllex stiniultition ot the sym-
p,itheti( nei \ous system As i mle he lies
inoaning Mith pun, the face pale, the ioatuies
diawn oi shmelled, the skin luid and moi^t
•\\ith a i old, < laiiunv swe.it The Umpoiatme i*.
below the uomial , the pulse small, weak, md
almost imperceptible and the lespnatious
shallow and megiilai The mine is scanty and
high-colouied, and the Mt il lo.utions giadually
dimmish In cases which piovo lapidlv i it il
the mind is deal at iust, ami may ionium so to
the end, 01 eoma may supoi \eue befoie de.ith
ensues In some eases, c's]M'(iallv in (hildien,
great ment.il excitement followed b\ delirium,
ciamps, and e omulsions aie maikcd clinical
features lieioie the latal issue
In many cases e\en oi yieat se\eiity the
patient shows a woudeiful dogiee ol apallu,
l^mg still, and complaining ot nothing c\cipt
gieat thus!
II .S'ljf,* f)/. Fnin \\D iM-Jwuninb —
This stage -the staye ot i<a(tion — begins on
the Mxoiifl OT thud da> The pun subsidi-s,
the appetite is lost, and i onstipation, oi it ma\
be djhoiitoiu. di.uihtiM, is pic>seut Theie is ,i
general eongestion of the internal MSI en, \ilnch
may give rise to \anous dmiial compliLations
Thus allmiiiniutHi is verj constantly piesent m
ciisoH of extenwne burmnif, especially when the
tempeiatme is i.used to 101° F or higher Ite-
sptratory coniphmtion\ in the formot bionchitis,
broncho - pneumonia, or pleunsy aie common
sequela) of bums, '•specially of those oecurrmg
ovei the thorax I .arj ngitis and oxloma glottidis
not infiequcntly follow scalds produced by the
inhalation of bteam, or fiom dunking veiy 1 ot
fluids or caustics
Tho nifeittnal compilations >««'y fioi i a slight
catairh with diaiihaa to s(\^*e degiees of in-
flammation and ulrei.it ion ot the intestinal
mucous membiane Ulcei itioii or the duodenum,
leading to peiiofation, has been obser\ed in
Vises oi se\oie burning, )jut its frequency and
( I inn al nuj)oi t.m< e appeal to h.u c been exagger*
,ited It has* been asui!)ed to the digestive
action ot tun gi^tnc juice on tho devitalised
mucous lining ot the gut
C'tt />i'il tinHjdi'ntioii* in the fcjun of nicn-
ni'iiti, of nieiititis .ue not lufiequent atter
bums implicating the scalp and ncik, and ue
p\id<nccd bv ceiebral imt.itioii or deliimni
iollo\\td ')\ convulsions and cjina
Mi HJ H,I (it Si ITU i i//«v —This stage begins
when the sloughs sepaiate, ind its duration and
somty lugely depoud upon the success \vhuh
attends the elloits made to sicuio <ibe]>sis in the
local condition In sc>veio c.ises with marked
septic in f ei tion it in a} be "veix piolougc'd The
patient m ad u illy loses stieuyth, and evidences
of septic* abruption in the1 toim of septiCconua
01 ]iy«uniia mamtcst thcmsehcs \t one tune
tetanus was a not infrequent swjuel Should
the suppuration be ]>ioiuse and long-continued,
wavy degcnoiation of the Iner, kidncjb, 01
intestines may supciM'iie, and death result
fiom hoc tic In this stage deith has bec-n
attubutible in some cases to p< itoi.ition of a
duodenal ulcei
LIU IL 7*777 WV7 A i — The deseiiption of the
difieic'iit dcniec»s of burns may be prefaced with
the lemaik, th it clinical eases almost imaiiahly
illustiate inoif than one device of burning
The deept r \aneties aie always accompanied by
those- of less seventy, and the clinical public is
made up of the (ombmed ih uactenstics of all
Fmthei, it may be said that it is otten e\-
tieuu Iv dillic ult to detoimme the exact depth
ot a bum luiuitihately attei it occuis, bome-
tunes it turns out less se\eic than it appealed
at hist siuht, but of tcncr, poihaps, moie so
/?/7iXso/- Jin Filial DK.IJ i Jlijimnmm or
JSiytlteuia — These aie usually pitxluccil by
llamo in coutict xvith the skin foi a \i»iy shoit
time , by sohdh 01 liquids below 100J G , oi
they may lesult fiom piolonged expo&ure to
the summei sun's lays
The pain is acute while it lasts, but it usually
passes otl in i tew houis The pait is of a
blight led or puiple hue, \d\ich disappcais
tempoiaiil} undei the piessuie of the iiugci,
and which giadually blends x\ith the normal
colom of the skin aicmud There is a transitory
bwc'llmg ot the burned area, with peihaps slight
oo/mg of bcimii fiom the suiface, .md the super-
tic i.il layeis of the cuticle usually peel oft later
36
BURNS AND SCALDS
THE SECOND DFI.RTF — Veucatian —
More prolonged exposuic to flames, solids, or
fluids at or above 100" 0 , 01 dncct application
of steam, arc tho common causes of burns of
the second dogiee
Here and there ovci an mea which presents
all the features of a bum of the hist degree to
an aggiavated extent, theic appeal, eithoi im-
mediately aftei the accident, 01, moie frequently,
not till some houis later, a numbei of vesicles t
or blisters Korh xesule consists of a laised
portion of epuleimis, iindoi which may be seen
seium of a yellowish 01 bio \\nish coloui Some-
times the vesicles buist, the seious 01 sanious
fluid escapes, and the suitace undeineath is seen
to be of a blight scailet coloui, the papillcU
of the skin standing out as hue \el\ety pio-
jections, excessively sensitive to piessuro 01
friction, and fiom which seious fluid fieely
oozes No peimancnt seal loiuams attei the
healing ot birch bums, but the pait may foi
some time show a slight depiession 01 daik-
colouied pigmentation Inlection by septu*
bactena m.iy induce supeificial suppmatiou,
and so delay lepan
BvR\'b o* i HI Tiunn DK.LH — Pattial De-
struction of the Ttue tikin — This usually lesults
fiom contact with hot metals, the piolonged
application of flames, 01 fiom fluids at a tem-
peiature abo\e 100° (J
The cpideimis, Malpighian la>ets of the skin,
and the papilhc arc moic or less disoigamscd,
and patches may be completely destioyed, leav-
ing hard, dry, and shiunkcn sloughs ot a yellow
01 black coloui, and quite insensitive The
sunounding aieas show damage to the hist and
second degiees The pain in these bums is
intense, but passes oil dining tho hist day, to
return again, howe\ei, when, about the sixth
01 seventh day, the sloughs sepaiate and expose
the neive filaments ot the underlying skin
Granulation tissue fills up the gap, and by its
contraction m.iy lead to a ceitain amount ot
depression in the pale scar which results
Jiuiw* OF Tin FUVKIII DH.KII Toted DC
stiuction of t/te Ttue Skin — \ny foim of intense
heat if sufficiently long applied may pioduce
burning to the fnnith degree The local de-
struction of tissue extends right thiough the
true skin and usually invohes the undei lying
connective tissue and iat Laige black, diy
eschars are foimcd, aiound which a ling of
white tissue is seen, and outside this a /one ot
intense congestion which gradually merges into
the normal skin As the cutaneous ueives aie
completely destroyed in burns ot this degree,
pain is not se\ere Infection is veiy prone to
occui by organisms passing fiom the sui round-
ing skin into the sloughs, and profuse suppuia-
tion often ensues Cieatiisation is always slow,
and leaves deep, niegulai, and often puck ei eel
cicatrices, which by then compaction in course
of time tend to produce \aiying degiees of
detoiimty aeeoidmg to then situation In the
region of the neck, the face, 01 the flexuies
of huge joints the distoition is often extieme,
and may call foi active suigical mtcifcience to
icmedy it
#PR\S OF mi Finn DHJRH - Chatting oj
Muscles — This degiee ot binning is frequently
met with m epileptic, apoplectic, or alcoholic
persons who, while unconscious, ha\e remained
foi a piolonged pel UK! in contact with hot
metal, flame, 01 chemicals All the tissues of
the pait down to the muscles aie destro>ed, and
joints 01 seious cautics may be opened into
Laige neives 01 \asculai flunks may be im-
plicated, and piotuse h.emorihage may occur,
either .it the time oi the accident, 01 latei when
the sloughs sepaiate by suppm.itiou Septic
infection oi .111} s}iio\ial 01 soious cavitv \\hich
happens to l>e implicated is moie than piob-
able
In many cases the oiih hope foi the patient
lies m amputation
/yi;?\s »>/ //// iS'/\/// Dunn Chutnur/ «/
7toy«s - When buinniu uocs to this extent the
icsult is usuallv fatal, and when ti limb is
impheated amputation is impel ative
J'atltotot/y of /fain* — The c.iuse oi death m
iapidlyiat.il, extensive, supeihual bums is the
chief point oi pathological inteiest It has long
IM en iccognised that the geneial lonstitutional
(list i IT banco lolloping extensive supeihcial bums
is piopoitionately iniu h gieatei than is obsei\ed
in seveie, deep burns AH Uaideen puts it,
"Theie seems to be something especially noxious
in the meieh supoincial bum " Such mjuiies
aie almost uimeisallv fatal, especially in childien,
when moie than one halt ot the sin face ot the
bodv is involved, even should tho bums be1 of
the most supeihcial kind Many thcones have
horn tmi(! to time been put foi w aid to explain
this fact Thus the MOWS that the giave
symptoms lesulting so oiten m death .11 e due to
mteiieience with the lespnator), the excietory,
the heat-iegulatmg, oi even the piotective
I unctions oi the skin, have each had their advo-
cates. Moio extended observation by modem
methods, howcvci, has thioun doubt upon most
of these theones
The chief naked-eye lesions found aftei death
have been a geneial hypcrdi'mia of the oiganu
of the alxlommal, thoiacic, and ceicbio-spimil
cavities, sometimes accompanied l>y seious or
sanious c>\udation —conditions which have been
attiibuted to a let lex \asomotor distin banco
These < hanges appeal to take some time to be
pioduced, because it death be very lapid they
are not observed If the patient survive a few
days, actne inflammatory signs may supeivene
in the intestinal canal, lungs, pleuia, kidneys,
01 momngcH, and ulceiation may follow in the
stomach 01 duodenum The lelativo frequency
of these lesions may be gathered irom the follow-
ing statistics of 200 cases by Schjerning —
BUKXS AND SCALDS
37
Hypera'ima ot brain occuiied in 49 pt
Hypei.emia of hums „ „ 36 ."> „
Ncphntis „ „ 28 2 „
1 'no ID HOD hi „ „ 27 „
Hyper.unua ot intestines „ „ 22 2 „
I'louiMv „ „ 18 K „
1 1 leer of duodenum „ „ 121 „
Meningitis „ ,,10 r> „
Theie is also a piotound .iLtoi<ition ot the
bloixl in these cases Its specihc j«i.i\ity is in-
creased, the pol) moi pho-nuc leal leucocytes die
incieased in nunihoi, the led tells inn togethei
and ultimately hieak down, and the hemoglobin
set fiee is deposited in the epithelial eHls ot tin1
tubules of the kidney, \\heie it pi oduces nuta-
tion followed by hfcmoglohmuiia
Thiombi and sni.ill extiaA.isatums are found
in inuny situations thionuhont the body, pi oh
ably due to the a< tion ol a tibnn-f( imcnt, of
which two ha\e been isolated, one a body like
muse arm, the othei belonging to the p\iidme-
ch molmo gionp
Some niteie'stmg ilimc.il and experimental
observations b^ Koiolenko thio\\ light on these,
nidi bid appcMiaiucs He found both in patients
<ind animals dying aftet se\eie supe-iheial bums,
that the ganglion cells of the solai plexus h id
undemoneeleireneiatne changes, \aiving, accord-
ing to the SL'M'tit\ of tin1 injiin, horn blight |
erdema to complete desti nction ot then pioto- i
pliism with disappeai am e of then nndei Fiom i
his expeiiments he concludes th.it the solai |
plexus is subjected to a ietl« \ excitation, which J
j>asscs out to the abdominal ciicul.ctoiy s>stem, |
piejduung spasm ol the \essels, includmir those
suppl\im» the u;anglia themseUe's, \\heieby
nntution sulleis In tin1 lapidlv tat il cases the
\essels lemain spasmodical!) conti.utcd, and
hypei.enna of the .vbdonnnal oitrtns is not
obsei\ed In the less seseie < ises the spasm of
the \essels is tollo\\e«l l^ a passue dilatation
A\huh explains the h\pei«emu oi the Msteia
The mtlneiK e ol the sol u plc»\us upon the heait
may also lx> a fa< ten in piodium<j: death
TJaideen has icc'entl) obsei \cd mai ke«i ehaimes
mall the 1 \mphatic tissues of the body, fioni the
small nodules of lymphoo tes in (ilisson's capsule
to the Latest lymphatic ulands consisting in
i^eneial u»doma*of the lymph tissue, espet lallv
.it the germinal centies, \\ith H\\cillm^ ol the
inclnidii.il cells and bieakinu' up oi then nuclei ,
and the appeal ance of certain larj-e flattened
endothclial cells haMiig a phap>i.\lu action
He also found in his cases inaiked cloudy spell-
ing of the Inei and kidney, and boitemn^ and
enlargement of the bpleen
The moibul findings tluoughout, thciefoie,
are so like those met \vith in diseases \\heie the
presence ot a tojine is known to produce them,
that it Hccms highly probable that death in
rapidly fatal cases of burning admits of a
similar explanation, although the source and
nature of the toxme aic as yet undetermined
Lwa? 1/iatolof/icfil ('hinges — The most note-
worthy changes following the application of
heat to the suiface of the body aie the coagula-
tion of the protoplasm of the cells, and its sub-
sequent disoigamsation The collagenons bundles
in the immediate vicinity ot the (haired tissues
become swollen and thickened, and huge irregulai
spaces aie foil nod by the sudden formation ot
steam in the tissues The papilLu aie swollen,
thickened, and sphencal, ami become loosened
iioni the epideimis liy the oxer-stretching ot
the horny layer of the skin and the sudden
exolution of ute.un, the epideimis IH laised, and
bulla- toim Into these seium, sometimes mixed
with blocxl, is (tlused The blood-\essels and
lymph.it ii s ol the tissues ni e se.ired and occ hided
The /one binioundmg the destioyed tissue is
contipstcil ami swollen, and shows considerable
infiltration wilh lciuo<ytcs The sepaiation ot
es< hats i^ ettci ted by the giowth ot granulation
tissue
TlthAlMIM
Oi iiu (ii \i /. n CtiMtiiniM — I) in ing the stage
of collapse 01 shock the patient must be kept
waim by means of hot bottles, \vaim blankets,
01 cotton-wool Ah oholu, stimulants, eithei bj
the mouth 01 as an em-ma, aiecleaily indicated,
and should be gixen fieel^ Hxpcxlcimic m-
jeitions of ethei, sti \chnine, 01 biandy may be
tailed ioi
When pain is sexeie, moiplna must be in-
jected hypcxlcimually
As nnpioxement takes place, hot dunks will
do good if the patient can take them
LIH u Tin \i\ii\i — It cannot be too stiongty
uiyed tint bums must be tieated on the same
iigidly antiseptic lines as othei snigual wounds
In tins connection it is impoitant to note that
Unn.i has imanably found p\ogemc bacteria in
the bull.c of bums
The hist step, theiefoie, is thoiough puiifua-
tion by antiseptic airents, and that this may be
satistactoiily accomplished a general ansosthetic
is in most cases neccssaiy In thc« subsecmcMit
diessmgs of extensi\e bums, especially in
child] en, the \alue of a geneial an.csthetic can
scancly be ovei- estimated The clothes are
caieiulH iemo\ed, the burned aiea thoioughly,
}et gcntlx, washed with waim boiacic lotion or
a 1 in 1 00 sol lit ion of h sol Blistci* aie opened
and the i.usc'd epithelium lemoved , and a final
wash with nomial salt solution, to get nd of any
excess ot antiseptic, completes the pielmuuaiy
puiihc.ttion
The loc.d application to be used depends
laigely upon the depth of the bum, its extent,
uid the time which has elapsed since its occui-
icnce In all cases the following indications
have to be met —(1) the iclief of pain , (2) the
pi even lion of sepsis , and (3) the promotion of
cicatiisation
Lin 17 TlllATMEM Of ItHlM /ll'B^nt /V«s/f
38
BURNS AND SCALDS
SECOND, Tuiu>, AND FOURTH DEGREE* — Picric
Add. — Within recent years — thanks to Thiciy
and others of the French school — we ha\o
found in picric acid an agent which meets all
our requirements in a way not previously
attained by the older methods It is employed
in solutions vaiymg in strength from 1 in 100,
which is practically a satuiatcd watery solution,
to 1 in 50 when alcohol is added It may bo
dissolved in sulphutic ether forming a solution
of about 1 in 20, which is painted on to the
affected aiea, and on the uvapoiation of the
ether leaves a covering of a very '/me po\vder of
picric acid
A useful lotion of moderate stiength is made
as follows —
Take of Picric acid 1 \ diachm
Absolute alcohol 3 ounc es
Distilled water to 40 ounces
Dissolve
After thorough purification of the binned
area by antiseptu lotions, pads of lint 01 sterilised
gauze aie lightly wrung out of this solution,
and applied over all the affected surface and foi
some distance beyond A modeiately thick
layer of antiseptic wool is put on ovei this and
retained in position by a bandage, pi el ei ably a
many-tailed bandage, to obviate the necessity
foi much movement during dressings A splint
to ensure lost IH .whantageous when possible
It is import, nit to obseive that the diessmir is
applied without any waterproof coveimg — that
is to say, it is not in the foim of a poultice
This dressing may be left in position foi fiom
three to seven days, accoidmg to the seventy of
the burn and the degiee of asupticity In bums
of the hist and second degiees it will be iound
that in three or four days all will be healed
under a single application In deeper burns,
especially when the asepsis may not be. absolute,
it is well to change the dressing on the thud 01
fourth day Any poition of the onginal di ess-
ing which remains perfectly dry and adheient
to the surface need not be icinovecl, but should
simply bo moistened by pouring a stieam of
picric acid lotion o\er it Any paits of the
dressing which aie moist fiom discharge must
bo removed, the surfaee thoioughly punned
with boracic acid or lysol, and the picric acid
pads reapphed The diessing should be icpeated
once or twice a week a< cording to circumstances
Among the advant<i</e$ of the picnc acid
method may be mentioned its simplicity arid
safety, as well as the mf requeue y with which
dressings have to be changed In a \eiy few
cases it has been iound to cause temporary pain,
but in the \ast majonty it is not only painless
but even anodyne Although not a powerful
antiseptic it is sufficiently strong to maintain
the asepticity of a bum which has been caiefully
punned at the outset Its absolute dryness is
an impoitant factor in pi eventing the develop-
ment of septic bacteria But its most valuable
feature as a dressing for burns is the marked
powei it has of promoting the proliferation of
epithelium — its keratoplavtic action — which
seems to depend upon the coagulation of the
albuminous exudatc fiom the injured surface
fonning a non-irritating, aseptic protection to
the young epithelial cells
Its only <?iw<f vantage* aie that it teinpoianly
stains the skin of the patient, and the hands of
the suigeon and muses This to a large extent
may be prevented by smeaiing the hands with
vaseline befoie using it, and afteiwaids washing
in methylated spuit or tuipentuu Stains on
cotton 01 linen clothes are icadily removed by
ordinal y laundry processes, but remain per-
manent in woollen and ilannel artu les
In a few isolated (,ises toxic symptoms —
nausea, vomiting, diairhcea, daik-colouied mine,
yellowness of skin, and drowsiness — have been
alleged to follow its use, but those who ha\e
had most expeiieme with pit in acid have not
observed any symptoms attnbutable to its
absorption The w liter, aftei an expedience of
over two bundled and fifty < »ses tu-ated by
tins method, has not xet met with any un tow aid
effects In joung childien the solution may be
diluted to about hall its stiength \\ith advantage
The tewlt* aie best m bupoihcial bums of
the hist, second, and thud devices, but the
agent is uselul as a piimaiy dicssmg in bums
of all degiees Artel the sloughs have sepaiated
and a gianulating surface is left, the usual
applu ations for an aseptic healing soie should
be substituted When the aiea is Luge and
uiatrisation slow, letouise should be had to
skm-giaftmg b\ Thieiseh's 01 ouu oi the other
methods available
Lhthyol ant/ Thwl — These, as antiseptics and
kcratoplastics, aie infeiioi to picnc ami They
both cause consideiahle pain when fust applied,
but this soon passes off If htltyol is applied as
a 30 per cent solution in watei , thiol, eithei in
watery solution I in 4, 01 as a powdei, mixed
with subniti ate of bismuth and a small quantity
of lodofonn
Aseptic Treatment — Mine Nageotte has ad-
vocated the tieatment of bums by simple aseptic
dressings after thoiough preliminary punfica-
tion with chemical antiseptics The results
have not been entnely satisfactory, doubtless
from the difficulty of obtaining absolute asepsis,
and fiom the absent e of any agent active in the
piomotion of epithelial regeneration
Moist Ajqthcatio ns , gieasy substames, like
carron oil, carl>olic oil, and boiacic ointment ,
substances calculated to occlude the bum, like
collodion, dry powdeis, etc , are only mentioned
to be condemned They entiiely fail to meet
the indications for the rational treatment of
burns on modem lines, and should be aban-
doned
TllFAlMhNl 01 CoMl'lHAUUhb liciial, pul-
BURNS AND SCALDS
39
ruonary, cerebral, and other clinic.il complica-
tions of bums «irc treated on the same lines as
Hirmlar conditions arising from other causes, and
do not call for further mention here
TRFUMEVL ut IUL /fosr//,so* JiuR^ — Ulcers
— Aftct the sloughs have separated horn a bum
and a stage of suppmation has been reached, an
ulcerated surface ib left \\lndi must bo ticated
on the pnnciples governing the management of
ulceis In the covermg-m of raw areas left by
bums, skin-giafting finds one of its most useful
applications Means should bo taken to pi event
the production of defoinuties by the conti acting
seais dining the healing of these uheis
G'wifmts — The < H atiu.es following bums
often constitute seiums dishguiomonts, many
ot which nicty be amended by plastic suigery
They aie also paituulaily pione to the vanous
diseases of cicatnccs (y w )
Dttmniitift — The conti action of extensive
cieatntes, especially in the legion of the face,
ne< k, and flexuies of joints, often leads to eon-
sidoi able d(.iomiity and mteiteience with finu-
tion, lor Tihuh plastie opeiations ma) do good
MEDICO- Lh(»\L Asians
For medu o lcg.il mqunies the following points
may be noted —
Thf Moth ot rtodwtion — Moist he.it in the
fomi oi boiling watei 01 steam leaves «i \\ide-
spicad, led, soft, and sodden (ondition of the
skin and undeilymg paits, without am actual
destitution oi tissues Diy beat fiom molten
metal, led-liot solids, lesms, eti , losults in a
moie limited damage of the tissues, v\huh VM!!
be blackened, dry, and moie 01 less completely
destiojcd by chaiinig The damauc done b\
boiling oils lesembles that iioui (by heat moie
than fiom moist, while flames produce injuiies
simulating botli The haus of a part aie
singed b4v diy heat, but leniain intact ,iitoi the
application oi moist heat
The J{{\nlt<< ot Ei plosion* — The injuiies re-
sulting fiom explosions oi gas aie ot wide
extent and sii])eifici.il, and consist ihiefly in
sioichmg of the smfaie In gunpowclei ex-
plosions theie aie numeious small paitulosot
i.uhon embedded in the skin
Jfiri* the pft\on at tin ot dead when oimud? —
In (onflagiations poisons an* often sufloc.itod b>
smoke, uases, en dust without being binned
In othei eases they may be killed by sulloc ation
and then burned If theie ate vesicles on the
skin, smiounded by a led and swollen aioa, and
containing M?IOIIS ot sanious mud, the pro-
sumption is that the person w.is alive when
burned The absence ot these signs, however,
does not negative the life of the pet son when
subjected to the fire, as they often take some
houis to appear, and death may have ensued
bcfoie they had time to form The skin under
a vesicle produced duiing life is intensely in-
jected, while that on a body burned aftei death
ib hard, diy, and yellow, and .my bhbtei which
may ha\e formed only contains gas It is to
be kept in mind, however, that heat applied to
a dead body while still warm produces appear-
ances closely resembling those of bums inflicted
dm ing life The main difference is that the
fluid in the vesicles in the formei (.iseisthm
and wateiy, and contains a \eiy small pro-
poition of albumen
In bums pioduced by red-hot solids during
•life the skin round the destiojcd tissue is usually
white, with a deep led ung beyond it hi a
dead body this1 red area is absent, and the whole
ot the destroyed suiface is deadly white
How IOIKJ (hd the jwrvm wivive the lummy?
- This question \\ill be answeied by noting
wheth'i tlioic aie present only the signs of
actual burning, oi whether adxaiucd inflam-
matoij signs have supervened Suppuration,
the s(paiation of sloughs, the foimation of
gianulation tissue, and the onset of gangrene
indicate a consuleiable lapse of time
MnikMrt Viol f net on a Jiutneil Jiody — The
body maj have been binned to conceal niaikb
oi violence (\ueful examination ma) leveal
hiuli marks, unless the destitution be too com-
plete
fyontaneoitb Comfwtton — It is almost need-
j less to sty that the belief that spontaneous
combustion may take place in the human body
can no loni>oi be maintained
Bums, Diameter Of. -The diameter
measuicd fiom the piomontoiy of the sacrum
to the ciest of the puhes, above the obtuiator
loiamen , the sacio-pectuical diameter
— Met illotheiapv, Pel km ism,
,SVf ll\siLiu\ (Tmitmtnt by
ItiUtoiatum
Bursse, Injuries and Diseases
! of.
Si I UM ION
INJLKILS
.Buusi us
(«)
(6)
(c)
(<l)
(t)
HURs I
Chi nine
(ttmoi I/ma/, lihenmntH
.JO
JO
H
41
41
12
42
42
43
43
43
Innocent
Maht/nttnt
tfee alt>v Ki now-JoiM, I.NJUiiihs AND DISEASES
(JJUmtn) , (JAMiLlON (DuUJtUWb) , Hir-JOINT,
JNJUKlhs (Jiurvil Enlargement*) t HlJ1 - JOINT,
Diht\sRs (Jiuritr) , KNEE-JOINT, DISRATES
(Buisvf) , SHOULDER, DISEASES AND INJURIES
(Jiit)t>a/ Enlai yements) , b^PiiiLih (Bin see)
INTRODUCTION — Two varieties of Tiursec aio
found, the tine and the false. A true buisa is
40
.*; INJURIES AND DISEASES OF
constant, \vhilo a false buisa appeal H ad A en*
titionbly owi HOIHC abnoimai piommence ot
bone, ey the so-called biiuuni, 01 the thickening
over the piomment spmous processes in an
angulai def enmity ot the spine The size of a
false buisa IH d lair indication of the diu.itioii
of the ahnoimal piommence of hone, and the
longci the false butsa has existed, the neaier
doe* it appioach in stiuctuic to the tine bmsa
A tiuu bmsa is a .simple hynoAi.il sac placed
between two suifaccs to prevent fnetion, and1
such sacs aiu eithci deep-beated 01 sube utaneous
In stiuctme a buisa is .1 sa6 consisting ev-
tcnitilly oi .ueol.u tissue of Aarvmg density,
and lined internally by a nioie oi less peileet
synoAial meinbiane of il.ittened cells The eellh
aie not continuous OAer the whole sinfaee of
the synoAial mem Inane, but <ue distiibuted in
patches, the spaces between being failed by the
ground substance of the eonnectne tissue of the
Avail Numerous bloodvessels and some ncrAcs
.ire found in the walls, and \\heu enl.u Cement
takes j)lace the Aessels increase in si/e and
number The cavity of a bin Ha, is a lymphatic
space in the same sense as is the synoA la! eaA ity
of .1 joint , in i.ict, a bin sal cavity is an isolated
artitulai cavity The. talse bms,u aie at hist
recesses in the sulx utaneoiis eonnei tive tissue,
and aie not bounded OA hue sjmrual mem-
brane, but nltei a tune patches of cells which
have an epithehoid itp])eai<ince .lie seen in the
Avails, and a moie 01 less peifect bin sal (.iMty
is foimed The svnoMal sheaths of tendons ate
true bin so), and iauhtate the moArements ot the
tendons* in their osseo-hbious giooAes These
sheaths in no way dittei in stimtme iioin buisa,'
SMU.MIONS or Ilii us i — In the head, nuk,
and tnniA Apait fioni the intia-.uticulai
synoual s.ius ot the tempoio-maxillary, Areite-
bial, and inteicost.il aiticulations, huisn; ate
heie veiy few in number An important one is
interposed between the posteiior suttace of the
body of the. hyoid bone and the tliAro-hyoid
ligament It sometimes becomes enlaiged and
toims an cne> steel fluid swelling, piojectmi; in
the ilooi of the mouth
In the ufflei tttteinity bursie aie At'iA
numerous An impoi taut one suigu ally is the
large snbscapulai buisa between the sub-
scapnlai is and the deeper muscles This buisa
is often the site ot the diy foim of buisitis,
when moAGinentsof the scapula become painful,
limited, and ai compamed by distinct creaking
If fluid is pouted out the scapula is displaced
hackwaids A large subcutaneous and often
false bmsa m found OAei the acioimon pioces^
of the scMpula, especially in those who cany
Aveights on then shouldetb In the immediate
neighbourhood of the shouldet-joint are thtee
bursto, one beneath the tendon ot the subscapu-
lans, which frecjuently communicates A\ith the
joint, one beneath the tendon of the infia-
spinatus, A\hich lately opens into the joint, and
one largo sac beneath the deltoid, \\ Inch has no
direct connection ^ ith the joint The in vesting
sheath of the long head ot the bu eps may be
legal ded ab a buisa between the tendon ot
the teres nnnoi and the shouldci a bursa is
occasionally iound, .ind one between the tendons
of the tetes majot and latissimus doisi In the
neighbouihood of the elbow -joint aie thiee A\ell-
known burs«e, one between the skin and ole-
ei.mon piocess, a second between the* tendon of
the triceps and the uppct pait ot the olecranon,
and a thud mtoi veiling between the biceps
tendon and the tubeiosity of the ladius >\t
the AM ist the tendons ot both the supeificial
and deep flevns, as well .is the median nene,
ate surtounded beneath the .umulai btiaments
by a laige loose synoAial mem)>iane A\hich
extends upwaids to the ladio-caipal aiticidation
and downwaids to a little beyond the bases of
the mctacaipal bones, being piolonged faithei
down in the tendons of the little finuer than m
the otheis A sheath exists mound the tendon
of the ilevoi lougiis pollicis as it passes beneath
the annular bi»aimnt and tommumeates A\ith
the large fle\oi buisa at the uppei boidet ot the
annul, u Imament The Luge buisa of the palm oi
the hand is impoi tant as the site of the so-called
"compound" ganglion 01 tuben ulai ionn ot Inns
itis Uencath the insertions ol the following
muscles bin s«e .tie found- extcnsoi eat pi ladiahs
longioi and bievioi, also between the suiface of
the totmei muscle and the supmatoi bievis Fal^e
buis,e also toim oAer the knuckles and intei-
phalangcal joints in those AA ho labour manually
In the jtelvtit and tower tttifnnty th»» hmsa
OAer the tuber ischn is laige and multilocul.u,
and iieipuntly enl.uges in tailois and A\IMAC'IS,
hence otiginates the cxpiession "wcaAer's
bottom" lieneath the glutens iiMMinus are two
))Uth.e, one miiltiloculai b(>t \\een it and thegteat
tiochantci, anrl one between the muscle's and
the Adstns extetnus Othet buistC aie found
beiuMth the insertions of the glutens medius
and minimus, while betwe««n the ohturatoi
inteinus and the m.ugm of the small sciatic
ioiimen is si buisa which is often continuous
with anothei betAAcen the tendon of the muscle
and the hip- joint At the liont ot the joint is
a buisa beneath the psoas A\huh often com-
municates AY ith the joint AhoAc the knee
thcic is a buisa beneath the qu.ulnceps extensoi,
also in communication with the joint The
hiiis&c in i elation with the patella and its
ligament ate tlnce in nurnbci In front of
the lower half of the patella and uppei half
of the ligament is tin1 pre-patcllar bursa of
"housemaid's knee" Ovei the lewei half of
the ligament is a second bin ha, und between the,
hgamc'iitum patella) and the tubeiclo is a third
buisa In the popliteal space aie the following
buibO! On the outet bide and aboAe the joint
are found one beneath the outer head of the
gastrocncmius, and one Inmeath the tendon of
BUUSyE, INJURIES AND DISEASES OF
41
the pophUuis, xvhich is almost always an oxten-
bion horn the first On tho outoi side, below
the joint an? huis<c between tho tendons of tho
pophteus .uid bnops and the c\toin.il lateial
ligament On tho imioi side thcio is a buisa
between tlio nmor hoad ol tho gastie>cnemins
and tho feinui, which is piolonqcd between tli.it
nnisclo and tho sonn-mombiane>sus, and often
coinmuiiK <itos \vith the joint Time is also a
luiis* between tho semi-memhianosus and the
hoad of the tibi.i xxhich is liequeMitly cnlaigcd,
and sometimes a bmsa between the Vndons oi
the senn-meinbianosns and scmi-tendmosus A
biiisa also sepai atos the tendons oi tin thioe
innoi ham-stnngs fioin the nitoin.il litii.il
hgimont, and is piolongod beneath the inseition
of the saitonus In tho foot, beneath the msei-
tions of tho tihialiH antic us and sometimes of
the peionens biexis a bmsa is found One
impoitant buisa is found between the uppei
pait of tho postonoi sin faces of tho os (aids
and the tendo Aclnlhs It is heqiiently in
flamed, and the atlottion so constituted is tailed
" Aohill(Nlyni.i "
iML'KiEh til Hints,* — These stint tuios, tioni
then exposed situations, aie ]>.iiti( ulaily liable
to tiaumata eithei of accidental and violent
thaiactei, 01 of a frequently ietuiiins» nitiiie,
and iiom the latti'i ouginatcs tho condition
known as chionic buisitis A blo\\ in the
noiuhhouihood ot <i buisa lesiilts either in <i
contusion aiound the buisa oi htemeuihago into
the« bin sal < ixity tioiu uiptuio ot the \essols
supplying it, an e\ent especially bible to ouni
in a hiemophilu, pitient, 01 the buisa is mp-
tiued, a \eiv piobable event if it ahead)
contains fluid, 01 it may be cleanl) toin o}>en
or laceiated liijuiios not sufficient to eiuso
sexeio lucmoiihago .ue foll«>\\ed by acute sei«>us
ettusion I Jut it luomoi i bane occur it m*\
oithei be absoibed oi sometimes followed lry
suppmation, 01 failing to be absoibed it lesults
m a h hi oid buisa Hlood miv b»» effused in
such lai go quantities as to mask a se\eie mjuix
ol tho bone beneath, ? i/ iiactuic oi the patella
01 oi the oloci anon
The tieatmont is as follows — If thoie is no
ahiasion of the suitaee a cooling application
should be employed for the hist thirty-six houis
and the ]>ait kept .it lest Then hot applica-
tions may be used to aid absoiption, assisted
by piessuie and gentle fnction Should the
pait become acutely mn.uned, it is IwtU'r to
m.ikc a fieo inusion, foi the luirsal sac is a
lymph spaee and absorption from it loadily
oecuis If the bins* is wounded or laioiated it
should be thoioughly cleansed with antiseptic-
fluids, and * gau/e diam placed 111 the ca\ity foi
two days
BURSITIH — (a) The Simple Aiut? Foi m (Acute
Hyqromd) is etiologieally of two \aneties, Trau-
matic 01 Primary, and Secondaiy from oxtonsion
of inflammation in tho ncighliouihooil Tiau-
matic hygroin* follows n»]uiies, especialK 1011-
tusions and ]>enetratin«; wounds, it it'iKtiii
in buis.u abeady milamed, suppuiation often
ensues, and hjgioma is oie.isionally seen horn
t \cessi\e o\ei-use The secondaiy form is due
to extension to the 1 mi sal sat of inflammation
in the McnuU, although the sae ma\ not \» in
dneit cominunication with the ]).nt At uto
seeontl.uv buisitis is thciciou seen in tonnec-
tion with a boil, (aibunde, ei)sipelas, suppma-
VINO aithiitis Thi secondaij toim is tithei
soious oi su])puiatno, and tho lattir is eithei
lot dised oi dffhiso The seious toim (acute
s<>ious h\«-;iomi) is at(ompamed bv phenomena
ot «jfia\ity su» h as \oiy acute ]>am, udness,
<rdema, nul tho ioimation oi a tnmoui often
within tin1 hist t^inty h«>uis It the eftused
tlui<l leiit.tins serous, tho swelling 1« ssens in h\o
01 si\ dajs, and the mflauimatoiv s^mptouis
subside, and the h\«;ioma nthoi <hs}ip|HMis 01
betomes «hionu, 01 ]>us m.iv ioim Sliould the
suppuiation be localised to the huisa, it will, it
lilt to itself, buist, nthoi oxtoi nail} and be
followed b\ the foimation of two 01 three
fistulous openings, attei whuh the buisa max
shiink and disappeai 01 it will nix ide the
noiuhbouimg tissues and cause extensixv cell-
\ihtis, ,nid x\e ha\«' seen a suppiu atmg buisa
patelltC followc'd by neeiosis of that bone *nd
by acute aithiitis The tio.itiuent is ovidentH
to O]H.MI the inflamed buisa in civ so soon a> anx
siihj>K ion ot pus ai ises
(ft) tiimjde Chnnni JiiDntti^ (Chumu Uy-
</unnu) — Etioloi/i/ It fiecHientlx follows acute,
but moie often is tho lesult ot oci \ipation, as in
housemaids, cobbleis, t.ulois, and mineis Vc«t-
neuil desciilu-s buisa? .is oMstmtl oxei turnouts,
ami Cnueilhiei met xsith a laijie seious buisa
between a mammaix stiuhus ami the pectoiahs
majoi l'ie- and peri-heimal c\sts .110 often
bin sal in then natuio False huis.o aio mot
with oxei the pionnnenees in club-toot and in
bunion The \*notios ol tin nine hxpomata
aie the cxstu, piohieiatimr, tibicjus, and hiomoi-
ihau;u \ t\«»tu h^uiioma is the most ticquent,
and 001 responds pathologically to h)diaithiosis
It is sometimes bi-lobed in shape, but is usually
mnlouiliu, i.uelv multiloc ulai The wall is
tomi>osod of thickened til nous tissue1, caiti-
l.ipnous in i>laces, 01 mciusted with calcaieous
yilaU's, and the hui*a often he's in a fatty
on x elope, if hy<iiom<i hjwmnttm rfe la mu/ue in
]M)iteis The contents aie either elo.u or opaque
thud, ol vellt)wish coloui, V.UMIIJJ: in consistence
and containing many chole^tei me ciystals
Soinetnnes, howexei, it is bloody oi puiulent
In the wall theie .ire often large aiUTies
piosc'iit, which may gi\e use to b.umoirhago
The piohferating Irygioma is geneiall} uni-
locular The cax ity contAius a xanable (juantit}
of liquid, and has loose bodies floating in it
which have been detached horn the intouoi of
the sac On tho lattei aie seen numeious
42
BURSyE, INJURIES AND DISEASES OF
vegetation-like bodies which aie wart-like in
appearance, sessile or pedunculated, and com-
posed of fibrous tissue infiltrated with cartilage,
and sometimes with 11110 acid or phosphate of
lime The hbrous hygioma is met with,
especially in iiont of the knee, as .1 him, m-
cl mated mass, in the centie of \\lne h is found a
little fluid The hicinoi i hagic hygioma is cithei
the result ot traumatism, or the1 blood may be
spontaneously eflused The fluid in the cavity
is thick tUid black, or may consist almost cntiiety
of clotted blood Volkmnnn has descubed a
pain] Id condition in joints as • pachysynovitis
hicmonhagica "
The symptoms of chronic buisitis aie not
difficult ot lecogmtion In an appiopiiate
situation .1 srn, ill lounded or flattened tumour
comment es which is indolent, neaily painless,
fluctuating, and on piessuie may be i oiled
undei the hand, giunu <i feeling of hue uepita-
tion A hbiotis hygioma is iiom the hist haul
and unyielding in ehaiactci , w lule ,i h.emoi ihagie
h\gioma has \ciy tew distinguishing eh.uactei
istKs The (ourse oi .1 hyp oimi is cluomc It
may dis«ippear entnely, OT it may undeigo pio
grcssivescleiosis and contiae tion oi itswalls The
i hiomcally enlaige>d buisa is exposed to luptme,
hamiori Italic effusion, and suppination li it be
subcutaneous!} nipturcd the fluid is absoibed
by the tissues, but the buisa leappe.iis
Ttentmrnt — Then* ate piacticalh two
meth(xls of tiealment — oblite tation and ev-
cision of the s,ir In the cailv stages of chiotuc
buisitis, it the nutating cause be icmtmd, the
buisa. will often subside, only to leappeai \\hen
the cause is at woik again (lountei-iiiitaiits
aie sometimes ot tcmpoiaiy seiviee The means
adopted tot obi itei.it ion ot the sac aie incision,
and the application of neailv pine carbolic acid,
oi simple incision and stuffing the caxity with
iiau/e, so pel nutting it to granulate up viitncly
But in all foims ot ehionic buisitis of long
standing, especially the piohfeiating and hbious,
complete lemenal ot the sac is necessity
— Allusion has already been made to the deposit
ot mate of sexla in the \\ ills of bms.e, and it the
subject be affected with well-maiked gout, this
stilt is often deposited continuously o\er the
whole interior of the sac and in its walls The
hursfcmost hequently aflccted are the olccianon,
patellar, and the subcutaneous bursar of the
hands and feet In gonoiihcea and acute rheu-
matism the buisa1 in the ncighhouihood of .in
inflamed joint often sj mpatlnse a< utel} In the
early stages a chy hygioma is pit-sent, which is
painful and finely crepitating to the touch, but
serous eflusion sets in to a ^ar\lllg degiee, and
the buisa shells Ncmic\\hat Its symptoms then
appioach those oi the serous vaiiety of acute
bursitis The diagnosis is made and treatment
earned out by recognising the associated con-
ditions
(J) Tuberculous Humtts — This was foimerly
thought to be laie, but many cases which were
published under the title of fungous disease of
the bursie aie now recognised an tuberculous
bursitis The sites ot the affection ate the olc-
craiion, sub deltoid, sub-ischiatic, pre- and infra-
patcllai, malleolai, psoas and popliteal biiisa)
Two vaiieties ol tubeiculous buisitis aie met
with, the prinuiy and the secondai} Of the
existence ot the formei thete can be no doubt,
and all conditions aie piescut m buisaj tor the
de\elopment of tubeicle in suitable' subjects,
such conditions being evposuie to injuiy,
abundant hbious tissue, and the pec uhar synovial
i haiac tei of the lining wall of the sac Secondary
bursitis is distinguished iioin piimaiy by its
being associated with tubercle of the neighboui-
ing joint It is not essential that theie should
be any direct communication between the
synoMal membianes of the buisa and joint
Pathologically thiee foims are lecogmsable —
fungous hyiiioma, hjgioma \\ith iice-giam
bodies, and myvomatous 01 nmcoid hygioma
Oi these the fungous liAgioma is most (ommon
in tjpe At first the c\st is snupl> scions and
its wall is nob thickened, but it soon becomes
copied by small tubeicles This st,«ge often
esc ape s obst-i \ ation, but latci gianulation tissue
toims .aid caseates, and }>us is seen, so th.it the
genei.il appeaiance of the ca\ity is like that of
tulxMCllloUS SMlOMtlS It IS ptob.ll)!} .1 slow
fen in of tuhciclc which .itfin'ts buis.e, as the
it-suits ol mo< illation of .inim.ils take a long
time te> appeal In the iite-uiam-bodicd hum
ot hvgioma theie- is !mt little fluid A laige
nunihct of these unions bodies is piewent, and
that they aie tiuly tube-unions is she>\\n b} the
lesults ot inoculation (Nic.\ise», Jht'u? (te dm.
l8S"i) This ioitn ot tubeiculous buisitis is tie«-
e\uently met with in the laiire palinai buisa, and
used to be1 kno\\n .is "compound g.mi;lioii " The
mucoid form of tubeiculous hjgioma has been
desc i ibed l»v Ciit/mann (Miih'cnie mix/ei n<, 1 800,
p (>,58) Theie is found a cvst tilled \\i1h gela-
timtoim mateiial, tiansluccMit and led 01 yellow
in colour The n.ituie of this mateiial has been
conclusnely pio\eel by inoe illation The symp-
toms aie those of a slow chiomc swelling, ofte»n
thick-walled and gmng the nupressKjii of a solid
bursa as the fluetuation is obscunvl In the
ncc-giam foim hue deputations aie picscnt
Unlike othei buis.e, the moie tube'iculous a
bursa glows, the softe-i and moie« semi-fluctuating
does it be'comc This is a diagnostic sign of
gie'.it ini])ort.ince Eventually a fistula toims,
but befoie that has occuucd, extension has
take'ii pl.ice to bones and joints The only pei-
nnssible treatment is extirpation
(( ) Syphilitic Jiumtii -It is met with in the
second, ti y stage ot syphilis, and .is the subacute
serous foim, and in the tertiary stage .is the
fibroid variety which becomes gummatous The
lattrr variety may occur as long as twenty years
BURSTS, INJURIES AND DISEASES OF
after the primary infection, and frequently followu
an injury The heat of election in the patellar
burea Tho progress of a tertiary syphilitic
bursa IH very blow, but ultimately tho tumoin
becomes adherent to bono or skin and ukciatrB
The diagnosis is often difficult, OH it in.iy be
mistaken for simple chronic hygroma, old hte.nr.L-
tonm or nodes, and when it ulcerates it may
simulate tubercle 1 1 IH, ho\v eve i , vei y indolent
and alow in prepress, but when small re.ulily
yieldis to treatment If ol Urge size ui ulcerat-
ing it Hhould bo completely return ed bj excision
NEOPLASM** — The iniioLeiit found met Auth
arc lihio-cuchondronia ;ind my \ouia The latlei
has been been by rhevasse thiec tunes In oiu
ease the tumour had attained the si/e of a child's
bend and VMH fioely ulcciated on the surf ice
Kihio-eiichondioina IH comparatuely i.ire ("on-
biderable difficulty is met itith in diagnosing
these conditions, und the icmoxal is 1ie«|iiently
undertaken, not because then n.it ure has been
recognised, but hedtnse of then si/e Malignant
new gio\vths aie either bariomatous 01 cndo-
theliomatous The sarcoma is either of the Hoft
01 round-celled tjpe, or is of the lapidly-hreak
ing-doun hrcmoi rhagu vaiiety With icfeiPiirc
to endothclioma, ])ollmi>ei has nut \vitli 0110
tase in .1 hstuloiis buisa of a \voman aged 58,
and Mukulici li.is seen a similar case The
softer xanetu'M of neoj)lasm may attain an cnoi-
mous size, und Itauke (Anlnv fin din C/in
1886) has met \\ith one G2 c/m in c irLiimfeicnce
The tieatment of these nenplabms is complete
remo^ al
BurSinlC Acid. — So named fioin IJnrw
jMtbton1* (shephenl's puise), fiiim \\hiih it is
obtained , it is lielm\ed to ,ut like cigotine
BlirsitlS. $
KASUh 01
Bushmen.
Bussorah Boil.
OlClhNIAllH
I'UHM, INK mis AND PLV
- --The name ^i\en to tuo isomeiit
hydiocarbous of the paialhn seiiew, which aie
colourlcsb, inll.imm.il )lc ^ases (1) noim.il
buttuie (butyl Jiydiide, dieth^l, propylinethyl)
la OH^CH.^:!!^!!, , and (2) isolmtanc (isobutyl
hydride, tiimeAhjlmethaue) is CH3(1H(tIHJ)2
Butcher's Pern ph Iff us- — Tcm-
phi^UH HiiitiiN ninli^niiH, a dibciise occurring in
those M!IO ate constantly handling meat See
I'EMI'HIUUh
Buteae Semina.— ihiie* ^eds, fiom
the Hutea fumdosa or dhak-tree, aie ofticial in
the Indian and Colonial Addendum (1900) to
the Bntibh Phai macopo?ia of 1H9S, in the foim
of Pulvis Buteif Stminum, they are gneii in-
ternally in place of bantonm (dose, 10 to 20
externally, they are used for a. 1111^-
worm paste } the oil obtained from the heeds IH
called moodooga oil
Butter, foe DIET (AfilJc and its Products)
— (1) The fatty substance obtained from cieam
by ill in mug, it contains casein, lactose, sails
(phosphates), \tater, and V.IIIOUH tats (^l)cencU'S
ol paliiiitii, btearu, oleic, biitynr, and i.ipnmic
•icidw), jilony with an aromatic piinciple (2)
TJic name is also ^iven to hut Lei -like sub&tunu'H,
hiich as blu-iL butter (the exudation tiom the
Arncan buttei-tiee), butter of cacao, buttcimc,
oleomargarine, etc
Butter Bad 1 1 US. - M} cobactenum
Imtyn >Vf TL IIKIICU MJ^IS (Dmy-ntnis ofJJacillati).
Butterfly LupUS.— Lupus eiythema-
toMis LI ll» d ni^ ihe biid^e of the nose and the
cheeks AV» Lurus KuiuiKMA'Kjsrs
Butterfly Operation.— A form of
postdiot (dlpuiihaphy ,See T'lfcHLs, DIM-LACB-
MLMM (Decent)
Butterfly Pessary.— An expanding
uterine siippoit, not now much used , X\vancke's
pessaij
Buttermilk. Me TNVAIID FEFDIVU
(Milk)
Butter of Antimony.— Antimony
chloride, used in the preparation of antmioiiioiiH
oxide, a poison /S'tc ANTIMONY, TuxifiiLOuY
(Antimony)
ButtOCkS. Xee IlLD-SoiiEs , RhriUM, DlS-
Button. — A small knob or disc, siuh as
the cauteiy button, 01 Cummin's button, or,
more speculh, .1 ]J Murphy's button (a device
used m connection xuth the opei.it ion for the
establishment ol intestinal anastomosis, to main-
tain the pitemv of the i.inal duiniir healing) ,
the name is also gixcn to Imtton-hkt; stint tines,
iiathold^u.il 01 noimal (e r/ Di^kia button or
iuttou de Ciete, and the umbilicus) Jiutton
truivy seems to ha\e been allied to syphilis (we
VENEREVL DISEASE, Aflml
Butyl AlCOhOl. — The ladicle Jiutyl
((!4Hi,) gr\es nt>c, in combination, to a number of
dei natives, including flulyl Alcohol (C!jH100),
Jiutt/f Aldehyde ((\HgO), Rutyl Jiiomide
((VInBr), fluty? rttlnial (CJjHr.CljC*) Chltnrttme
(hypnotic) is a tnchloio deiivatixe of butyl
,dcohoi r
Butyl Chloral Hydras. — Butyl
Chloral Hydiate, wion^ly named croton chloral
h>drate, CjH^ljCHfOH^, it IB prepared by
l passing di\ chlorine gab thiough aldehyde, the
butyl chloral thus tormcd is separated and
water j» added , it rcbemblea chloral hydrate in
its action, and has been used specially for
neuralgia of the fifth nerve (dost-, 5 to 20
grains) ; it dissolves freely in spirit.
ne of the olchnes, formed in
this dry distillation ofco.il, etc,. (C,HS).
ButyphUS.— The cattle plague
Butyric Acid. AW MICRO-OIK: \\ISMS
(VertHenttihtHiti). — This acid ((\llj)») w formed
during the oxidution of butyl alcohol (<•.//
during the fermentation of chqcHo) ; it has been
used as a hypnotic.
Butyrometerand Butyroscope.
— Instruments for dctci mining the amount of
fatty matter in milk.
Buxine. — An alkaloid obtained from
fiiuiti* mv/f/ffrr'iwMJt, and probably identical with
ffrfortnf ((',SHMNO,) ; Imxmidm is found
with it.
Buxton. AW BALNEOLOGY ((treat /irttnin) •
HYIWOI'ATHY , TllKllAPKmiCH, HEALTH U&sOJiTH
Bynin. A proprietary liquid extract of
malt.
l. Au emulsion of cod -liver od in
extract of m.ilt.
Byres. AW MILK (CW*Wx).
Byrolin. — A mixture of lanolino, glycerine,
and boric acid.
;„ — A pneumonokoniosis, due
to inhalation of cotton fibre ; byssophtlnsiH.
(AW Ll'M.S, 1'NEUMOMiJvONIOSlS).
Cac- and CaCO-. — In compound \\ords
"cac-" ami "caco-" signify bad, ill-conditioned,
evil, or morbid. Tims tvinnntit is a morbid or
depraved state of the blood ; MCti'st/iesia is an
unpleasant sensation ; wwhulin is a depraved
state of the bile, and mrurhyhn, of the chyle ,
cumrhffmni is a mm bid st.ite of the humours;
cdfttcnlftin is \ulvargaiigrene, woy/owm is gan-
grene of the tongue, canqnieHmonia is gangrene
of the lung, and cncoxtuHint is gangrene of the
mouth ; rticonyehitt is a morbid stiite of a nail,
and <ymM/*fi-»ifri, of the semen ; etc., etc. See
also MI/W.
Butter.- -A concrete oil (Oleum
Thntftrttmntm) got from the seeds of the chocolate-
tree (Thftthmmn rnnto) of the Natural Order of
the Sterculiaceso. liy varying the process of
preparation, cocoa and chocolate are obtained.
Cacao butter is used in the making of supposi-
tories (except those of glycerine) ; it contains
chiefly stearin, some olein, and the alkaloid
theohromme.
GaCCagfOgue. <SW AI-KKIENTS, PURGA-
T1\K«.
Cachets.- Wafer papers for uoncealing
the taste of nauseous drui>s.
Cachexia. »V<v al*o (iorr (Chrome and
Jrtv;/nlitr) ; MALAKIA (^ftjvfftf) ; MAMMARY
(iljAM), I»^KAnKN OK (Ctim'nomnttl) , UNOOK-
SCIOUSNKSS (Auto-tnto.riC(itions, Cnr/ifjria stt'umi-
pm*t).--rV\iw term, derived from the- Cireek
words K«IW>S' and cgis, and meaning literally a
bad habit of btxly, is one \vlucli baa been used
from the very beginnings of medicine. It. never
has had, lumevcr, a very precise meaning, and
the following is its definition as given by Cope-
land : — " Depravity of the constitution, without
fever, afttoting more or less the solids, the cir-
culating Hinds, and the secretions." In this way
cachexia is to be regarded as meaning the out-
\\ard and mainly the facial expression and
cliJiracteristies resulting from the profound and
complex changes in nutrition induced by a
malady of some chromcity. It is to be noticed
that cnchexia is to be distinguished from dia-
thesis, by which is meant a constitutional dis-
position in virtue of which an individual is liable
to certain loeal affections of the same nature. It
is also to be distinguished fiom the malady ac-
qmrtxl :is tho result of home innate weakness or
unhealthy surroundings, and no less from the
conjoined symptoms and signs of the disease
induced by such.
With the diathoms, \\itb the conjoined symp-
toms, and with the malady itself, it has, how-
ever, frequently been confounded, and its dis-
tinction as a term from marasmus, djHciusia,
and many others, is not well marked.
There is no doubt that as our knowledge of
healthy and diseased processes is becoming more
exact, the term cachovia is bc'comnig less and
less made use of. In olden times the ciwhcM.is
and the fevers shaied u great part of the
physician's attention, \\hilst mm, the tern-
mentioned in a text-book, is seldom deemed of
sufficient importance to merit a, place in the
index. For this disuse our more precise know-
ledge of disease, and our clearer grasp of the
association of symptoms, form, as has been mud,
tho explanation. The terms cachectic angina
and cachectic liver abscess, of a previous genera-
tion, are hardly ever used now, the sore throat
and b\er abscess being ascribed to infective
organisms acting on an individual of lowered
nutritive power. Further, the scorbutic
c.ichexiit, the syphilitic cachexia, the caidiac
eachcxia of the French \\ nters, and many others,
are recognised now rather as a more or less
definite, association of certain symptoms or signs.
It follows, therefore, that although in reality
every disease has its cachexia, yet the cachexias
\\lnch require detailed consideration at tho
present tune are only three in number, viz. tl
cancerous, the malarial, and the metallic.
CACHEXIA
45
Cancerous Ctuhum — -]ty this is indicated the
hicidl aspect and the geneial appearance of
feebleness and loss of flesh met with in individuals
who have been foi some time sufie'iing horn ean-
eerous disease In its nuikedfoi DIN the f.u eispale
\\ith a jdlovv 01 gicemsh -yellow tint, the cheeks
hollow, the nose pointed, ,md the eyes sunken
roirewp* Hiding with the eni.u i.ition ,ind muscu-
Lu weakness the movements oi such j),itienth
ait1 slow, and ,is the lesult ot the «miio 01
less constant p.nn, and of the gciiPi.il ui}»aiiif
sensation oi nn\\ellness and fertile ness, the
cxpn> Mem is sad and gloomy and betokens
sunVnng Thecoloui ol the skin in suehi.ises
is due to changes in the blood ,ind skin pig
ment, and these in then tuin aie piohahly
hi ought about by the lesoiption into the blood
of the Hind seuetion of thceamei nils It is
to be lememhemi, on the om> hand, that the
canceioiis c«ie_hexia ma\ be e loseh smiiil itcd l>\
othei ID 01 l)id conditions, and, on the othci, that
cancel maybe picscntand \ctc.iusi no cat IUM.I
This lattei might be explained on the j^iound
that little ot no pain is pies< nt, and that no
lesoiption is taking pl.u c ftom the diseased
mass It would set in that the eaehc'xia is
usu.illv most evident ineaseseif ulcei.itiny < aneei
.uul in c.ineeis allcdmg the4 stom.uh, intestine,
«ind tongue
Malm ml (!<i</itiin — H\ this is meant the
t luinues which are ,ipt to siipei \ene in .in null
\idti il \\ho has siiileied horn one1 01 mou attae ks
ot in ilaiial f( vei, 01, but to.i U'MS extent, who h.is
been loi long times c\]>osed to malarial ]>oison
It is associated spe« i.illy with changes in the
blood find spleen, but the h\ei, kiehie v, and
neivous system aie ipt also to show moibid
changes The eae he\ia shows itself pimupalh
in tin1 (oloui ot the skin It is pale, le-
semblmg in this lespect oidmaij ana'ima,
but it often leveals i \elle>\\ aspect, whuh
h.is been compaied to that ot old wax, oi «i
biownish coloui, which has been coin pa led to
that of giiigcibic.ul Witli tins the atteetul
individual usualh piesents an aspec t of nuiked
feebleness, .uul shows a pioncnesh t«xliops\ of the
dependent paits
Mtalltc fVic/tftf'fs—Oi these the lead and
the meiuuial aie the example's whieh ha\e
i eeei\ed most attention The lead is the only
one which incuts heie detailed lefeienee Tln,s
cachexia, which lapidl} manifests itself in indi-
viduals who ha\e been exposed to the causes of
le.ul poiHomng, consists mamlv in .in alteiation
in the coloui of the skin This in its pal loi
lesembles aiio-'mia, but diHeis fiom it in pioent-
ing, .ilong with the palloi, an .ippeaiaiKe of
what is best expiessed by dntiness, the icHiilt of
the piesence in the pale skin of minute paiticlch
of lead In addition, the blue line along the'
softeneel gums, the fatoi of tho breath, and
the peculiar paralysis, etc , rendei its lecogm-
tion easy
Cachexia Africana. — Afnum 01
Negio cachexia — the lesnlt, peihaj)s, of dut-
eating .imong the ,\iiic'an natives , cachcxia
a<mos<i, possibly the same disease as minci'H
anaemia
Cachexia Sat urnina. ^ cv
(MetiMu)
Cachexia Strumipriva.— A n '
st.iite,allieeltomyxa'dema , ope-j itue myxa'dema
»sVf Tin, toil) (JiA
(1ai"d\J, <>i duiecxhl, 01 d nsente tiamc'thyl,
exists as caeod\l e»\idc ( Xs^^CH ,)4) 01 Cadet's
fumin-j; Jii|ind , it has a poweitully oftenvne
odout , t on il c,uod\lic acid is obtained by
cxpo-uic,1 t< tli- an , theie .»ie also -..ilts, such as
s(«liiiui ,u id ieinc <acod>late, which aie used
medu mally , .1 salt somewh.it analogous to
sodium <a<ol\late is emplo}ed in medic me as
fitt/ienal, and h.is tonic piopcitit's
CaCOetheS. -( '<t< octhes me ins liteially a
bad habit, 01 an ill-conditioned or c>\en in ihgnant
state The m\cteiate tiamp, well known to
woikhou.se aiithonties, is said to ha\e the
I tl < w f/lfi, fl HI // llld IK 1 1
____w _..__.,„ — Abnoimal foimatiem,
sueh as is seen in tci.itologital 01 pathological
conditions
CaCOpathia. — \ scveie maladj ot the
mind (01 body)
The perception of a bad
CaCOSmia. — UK peiception of a had
rxloui, due eithei to its actual existence (toieigu
body in nose, disease of sinuses, etc ), 01 to a
ilisoidei ot the oltactoiv neivc ti.ut XifNiisK,
\ \s\L NFllttlsFs
(xloi
I
d
\v
CaCOthyiTlia. — V dcpiesscd mental (
dition, with depi.u.ition ot the moials
Cadaveric Rigidity. AW M
IMIHLNSK (Sit/nn »f Death, Jttyoi J/mf/s) , ruhu-
N\NO, iMHA-l.LLHlNh DlM- AM«S (IJiatll <>t /'« /Ms,
Cadaver ine.— v ptomaine ((^HL.NJ
obtained iiom human icm tins in the latei stages
ol decomposition, a liquid having a veiy dis-
auiecable smell >S'u JVIMUMI\ (Immunisation
H'tlh T<nn J'ifttfitt\), SVVKF.-KIIFS \MI POISONOUS
b'isiiLs (I'utH faction nt /Wi), ITniMi, l^nio-
loe.K'Ai, C'n\M.bs IN (l)tnmtnnna)
Cade, Oil Of- — Jumpei tai oil oi Oleum
Ctulniuai is a VIM id, oil} liquid, with a tai-like
smell, piepaicd by distillation ot tho wood ot
the Jnnifn'im Oii/ctdi «A, and acting beneficially
in such hkm diseases as cc/ema, psoiiasis, and
piuntus It is used as an omtmcut (e </ melted
with an equal pait of yellow wax)
46
GADENABBIA
Cadenabbia. See THERAPEUTICS,
HEALTH RESORTS (Italian Lakes)
Cadmium. — Cadmium (Cd) resembles
zinc m its chemical relations , in the form of the
sulphate it acts locally as an astnngent, it is
not official The iodide (ten grains to one ounce
of vaseline) has been used as an ointment in the
erythema tons stage of at no losacea
CadilCa. — Thcdeudua tite FCETUS AND
OVUM, DEVELOPMENT OF (Deiidua)
Caduca Passlo o/ Caducus
WlOrbUS.— Kpilepsy , the "tailing sickness "
CfiBCitaS. — Hlmdncss, e rj '.ccitas vet lalt s,
\\ord-blmdncss, cwutas tuntiiM, hcmeialopia
.— The caput mil ot the'mte-tme
Kee Ari'LNDix VjiHMii-oRMLs , HERNIA \(!(wyenital
Iferma of Uvcum) , TVPHI ms
Csenesthesis.
• c\i
. A genii* of -In..),-, and
ticcb of the Natuial Oidei ot the Leijmmnos.e
The seeds of (! tin/fan* aie used in iu.il.UKi,
and those of C Honduc as a tonic and .Jitliel-
imntic as \\ell as in malaiia, the lea\os ot the
lattci aio said to act as an emmeiuiio.'ue The
C pulJienimn has seeds and lca\es >\hich aie
dint etic,pui?ati\o, and ahoi tifac lent , its pods aie
asttmgent The seeds of the C SapjMtn ot India
act as eininenagoirues
Caesarean Section. *<>' LAROLU,
Ol'KRA'llONS, IjAHOUJl, I*HOIX)M»Eli {('onftttibfl
7W/'?«.), PithtiNAM \, An'hrnoNs OF CJFM-RVTINK
ORGANS (Fihtoul and Ovmnin Turnout \)
CaOSlUITI. — An element (C's) li.nnio nil
atomic A\ eight of 1.33 , it lesembles potasMiim ,
and is contained in the iaie minoial jmllu*
liionudc oi (<uhium has In-cu used as a sedatno
in pl.ue ot })romide ot potassium
CaffeaniC Acid. — Caneanie acid,
cafledii, aud, ctijftotannu aeid, and aifftifn and
are acids obtained tiom toth'e, tafltone is the
fiiouiiitu pimciplo of coilue, and tuffeidtne is an
alkaloid (C-HJ.N jO) j^ot by deeoinpfMii^ catti me
<7").I
Caffolna. X<? also AIK \LOIDS, COLOUR
VIMOX (Aiyuned Colour-Id tnt/nt «»s), DIITRRTIN,
GuAitAVA , I'ITARMACHHXMIY , etc — An alkaloid
((1SH1(,N,O,, H_jO) obtained fiom (oinmoii tea
(CtiHitllia tin a) 01 colJee (Cnffut at aim a), and
kmmn also .is Theme 01 (hiaiamne It is a
methvl deii\ati\e ot \antlnne, and i*> thus
related to theobioimne, foi caffeine is ttimethjl-
xan thine, while theobioimne is dimethyKanthine
Caflfeme cm br made quite soluble m cold \vatci
if half a ^lain of scxhuin sahc^late foi each jjjiain
of the caffeine be added It may be given in
doses ot 1 to 5 grains , but its salt the citrate
is more often employed Caffeince Citras \&
official, and may bo given m doses of 2 to 10
grams, oi m effervescent form (Cafnnm Citra*
E/e» vescens) in doses of 60 to 120 giains In-
compatibles aio poUssium iodide, mercurial
salts, and tauiiic acid
The chief ai tion of caffeine is to increase the
force of the heait's action and to laise the blood-
piCHHiue It also stimulates mental activity,
and acts as a dmictic It is used m heait
disease for its stimulant action, and it is
specially useful \\hen theie is concomitant
choppy It lias the additional advantage that
it can, when mixed \\ith solution ot sodium
htJicvUtc, be gnen hypcxleimicMllv It is used
in poisomnn by alcohol and opium The vnlen-
anate has been used in \\lioopmu-couuh and
hysteii.i, and the ai \enute m malaiia
CafifOt. — r*am»b is the name t;iMii to eei-
tain piosdibed laceslnum chiell) in the IUs«|iie
l'io\ lines They weie not <ietins, possibly
the\ siitleied tiom a mild tot mot hpiosy The
"I'.ii^it K,n " has been legudetl as a chai.u
tenstie m.iltoimation , but this seems to be
'•pen to question
Caisson Disease. Compic-ss^i- m
Disease 01 Duel's I'u.il^sis Me SPIN*, Suu-
dll AL AllH llO.Ns Of , VliRIK.O
CajUpUt Oil.— The >olatil< oil (Oluun
Ciijtijmtt) isdciued tiom the leaM s ot Mtlnhura
lnnn<f< ndnm (OT J/ minot), and is i l)lmsh
giecn lupnd (ontaming h)dious lajujuitene,
<ajii])utol, 01 ( meol (euc.ihptol), C]()H17()H, and
teipmeol, as \\ell as aldehydes(but\iu , lu»ii/ou)
ft is L»i\en m doses oi J to .3 m , 01 as tho
fymilHs Ctijiijniti in doses ot ") to 20 in In-
tel nally it is taken (on sugai) foi ( olic, toothache,
neuiali^ia, IIOIAOIIH vomitmir, «hsnienoiiha.i,
etc, at tins; then as a laiinin.iliu' and anti-
spasmodic , cvtcinally, it is used as a stimulant
and (ountei-iintant, as m chilbl mis and ilnoiuc
iheiimatism
Calabar Bean. $?<> rmsosiu.M^Ms
SMILNA, TOXK'OHM^ (AlLalotdt)
Calamlne. — Vatuc /me caibonate,
c.ilamm.i piiepaiati contiims t hiefly 7inc c.ii-
bon.ite Avith oxide oi 11011, etc
Calamus Scriptorius.— The loner
end of the tomth ventiiclo ol the biam, ter-
minating m a pen -shaped point Me? I'm MO-
LOO* (AVj WMS tiy\te>n, Vaso-motot Mcthanwn)
CalCaneO-CaVUS.- -A vauety of club-
foot (7 v )
. — The os calcis in heel
bone tfee ANKLF-JOINT, IN JURIES (rteutmeof 0*
cakis)
Calcareous Concretions and
CALCAREOUS CONCRETIONS AND DEPOSITS
47
Deposits. See MENINGES OF THE CEREBRUM
(Minor Conditions) ; TONSILS (Chronic Tonsittcer
Abscess)', TUBERCULOSIS (Morbid Anatomy);
TUMOURS (Myomata).
Calcareous Degeneration. See
ARTERIES, DISEASES OF ; CALCIFICATION ; HEART,
MYOCARDIUM AND ENDOCARDIUM (Infiltrations);
PREGNANCY, DISEASES OF PLACENTA ; PREGNANCY,
INTRA - UTERINE DEATH OF FOSTUS; TKHTII
(Diseases of the Pulp).
FiSSUre.— A cerebral fis-
sure joining the parieto- occipital fissure, and
helping to mark oft* the cuncus. /SV« BRAIN,
PHYSIOLOUY (Anatomical); PHYSIOLOGY, NEKV-
ous SYSTEM (Cerebrum).
Calcification.— An abnormal deposition
of lime salts (carbonate and phosphate) in the
tissues, especially in those which are useless,
decaying, or dead (e.g. blood-clot, dead fu)tus
(lithopeedion), caseous masses, senile arteries,
heart- valves, pleura, pericardium, splenic in-
farcts, etc.). The cause is uncertain, but neither
an excess of lime salts in the blood nor their
rcsorption from bones has been proved ; it is
probable that a depreciation of the nutrition
of the tissues is a necessary antecedent to cal-
cification. See ARTERIES, DISEASES ; LIVER,
DISEASES OF (Calcareous Infiltration); TUJHJR-
CULOSIS (Morbid Anatomy).
Calcium and its Salts. See
HEMOPHILIA (Treatment) ; PANCREAS, DISEASES
(Chronic Pancreatitis, Treatment) ; PHARMA-
COLOGY ; PRESCRIBING ; RHEUMATISM, RHEUMA-
TOID ARTHRITIS (Urine); STOOLS (Unteroliths);
URINE, PATHOLOGICAL CHANGES IN (Metals, and
Calcium ojrafate).
Calcium Carbonate is official in two forms • —
1. Creta Prejntrata, a dull -white powder, in-
soluble in water. Dose— 10-60 grs. /'rqxira-
tions — ( 1 ) Hydrargyrum cum Creta, grey powder.
Z>o*e— 1-5 grs. (2) Mistura Cretaj. Uose—^-l
fl. ox. (3) Pulvis Crctiu AromaticiiK. Doxe—
10-60 grs. (4) Pulvis Cretaj Aromatujus c.
Opio. Dose — 10-40 grs. 2. Calcii Carbrmas
Prcecipitatus, a white insoluble powder. Dose —
10-60 grs.
Calcium carbonate is protective and mildly
astringent, and prepared chalk is therefore use-
ful as a dusting powder and for application to
moist eczema. It is also an excellent tooth
powder, cither alone or made into a paste with
antiseptics. Internally its action is limited to
the alimentary canal, and it is given for diarrhcua,
especially in children, in the form of Mistura
CretBB or Pulv. Cretaj Aronmt. It is also useful
in some cases of dyspepsia with hyperacidity.
Calcii Chloridum is in the form of white
masses, very hydroscopic, and soluble in their
own weight of water. Dose— 5-15 grs. It is
given where there is a tendency to hemorrhage,
on account of its power of increasing the coagula-
bility of the blood. In haemoptysis, hrema-
temesis, aneurysm, and so on, where the blood
condition is not the cause of the hemorrhage,
it is useless ; but in haemophilia, jaundice, and
other diseases predisposing to bleeding it is of
great benefit. Operations for abdominal diseases
associated with jaundice should always l>e pre-
ceded by a course of calcium chloride.
Calcii Hydros, slaked lime, is obtained from
the interaction of water and lime (Calcium
(Jxide). 10 is a white alkaline powder, soluble
1 in 900 of water; 1 in 60 if sugar be added.
Preparations— (4.) Liquor Calcis (lime water).
Dose— 1-4 fl. oz. (2) Liquor Calcis Saccharatua.
Dose — 20-60 ui. (3) Linimcntum Calcis, consist-
ing of equal parts of lime water and olive oil.
Slaked lime mixed with caustic potash has been
used for destroying warts. Linimentiim calcis
is recommended for burns. " Carron oil " con-
sists of equal parts of lime water and linseed
oil. Lime water is used to prevent the curdling
of milk in the stomach, and is very efficacious
in the vomiting of infants ^hcn that is due to
rapid curdling of the milk. It may also help
in checking a mild diarrhoea.
Calcii Phosphas, derived from bone ash, is a
white insoluble powder. Dose — 5-15 grs. Pre-
paration— Syrupus Calcii Lactophosphatis. Dose
— £-1 fl. dr. It has been used in amumia, rickets,
and various forms of malnutrition, on purely
theoretical grounds ; but very little of it can be
absorbed, and it is more than doubtful if it does
any good at all. If used it should be given in
large doses.
Calcii Hypopfwsphis is soluble in water. Dose
— 3-10 grs. It has boon used for the same con-
ditions as the phosphate, and is probably more
eflicacious because of its solubility. The Glycero-
phosjrtate of Calcium is very popular as a tonic,
and it certainly seems to do good in some cases.
Cats tiulphurata is a (lull-grey insoluble powder
with an odour of sulphuretted hydrogen. Dose —
j-l gr. It has been recommended for all kinds
of suppurative processes, particularly intractable
furuuculosis. There is no proof that it has any
effect whatever in checking or relieving such
conditions.
CalCUlUS. Aftv BLADDER, INJURIES AND
DISEASES OF (Calculus Vesicoe) ; CHILDREN,
CLINICAL EXAMINATION OP (Uritmry System) ;
GALL-BLADDER AND BILE Dutrra, DISEASES OF
(Cholelithiasis) ; KIDNEY, SuRuiCAh AFFECTIONS
OF (Pyelitts, titone in the Kidney) ; LACHRYMAL
APPARATUS, DISEASES OF (Excretory Apparatus,
Calculi) ; NOSE, FOREIGN BODIES (Jihinoliths) ;
OBESITY (Pathological Inflations); PANCREAS,
DISEASES OF (Pancreatic Lithiasis); PENIS,
SURGICAL AFFECTIONS OF (Prejtutial Calculi);
PREGNANCY, PLACENTA, DISEASES OP (Calcareous
Degeneration) ; PROSTATE GLAND (Prostatic Con-
cretions); SCROTUM AND TESTICLE, DISEASES OF
(Scrotal Calculi); URETHRA, DISEASES OF (Cat-
48
CALCULUS
culi) , TRINE, PAIHULOGICAI CHAM.KS IN (Uu-
tutiy Ctiltult) , VEhicuL,* SEMINAI KS (Cnliult)
Calcutta Fever. — lUstaid typhoid
fevei *SW TROIMPS, -IHF I' NCI \sshn FE\FKS
OK 'I UK
Caldarium. -The hot <hambci \\\
the antii'iit lloman baths .SW IJ\i\H>i<x.^
Caldas da Rainha. >>'«• H\I
(7*07 f
Caldas -de-Gerez. ,sv< BMNFOIOM
(/*o» tuyul)
Caldas-de-Montbuy. .sw BMM-O-
IXXil (tijMUH)
Caledonia Springs. ti« li\T\ro»ux,v
Causing heat,*'// Em/Ja^
tr urn ( 'aletacten* .SV<j ( ' \M u \mi>hs
Calendar, Obstetric. <sw PHE<.
XAV\, DIAGNOSIS (I'mfa/ile J)ate of Confine-
ment)
Calenture.— Fe\ei, especially of theimu
causation, aih»( tm<> sailois moic paitu ulaily, in
the tiopics, theimu fe\ei 01 ho.it apoplexy,
sn laws iSYv SL N s i u< >KF
Calf-Lymph. AVc VAtciNAnos
Calvary. >SVf TnnKArhL i K s, HEALIII
HJCMIKIH (Ai/tencnn, ttntidi Coluntlna)
CallCO-DyerS. ^ TR\I>I<S, DANOKKOL.^
( Lead-Poiwm ny )
California.
(Auiettutn)
THFR \PEUIICS, HFM in
Call I per -Com passes or Cal-
lipers. — A bolt ot compasses, \\ith attached
scale, lot incMsinm^ tho diainotcMs of convex
bodies, suoli as the fa-tal he.id ((VphdUniiftoi)
01 niak-in.il ])i>his (IVhunetei) »SVf LAHOLK,
l*RhTII'UMF AM) l'l{l)M)M.Pl) (I'fh'imeh y)
CalllrrhO^. .SW IUINKOIXXA (Tin ley,
/Wtstine)
CalliStheniCS.— Simple gymnastic exci-
dses, einplovod to pio\t»nt or < uic spin.il cui\,i-
liuc, especially in ymni; t^nls »Vcr SPIN*,
Call OS it as. — A local thickening oi the
homy l.ivets ot the skin (hyporkeiatosib), oocui-
1111^ espcmllj on the palms and soles, due to
continuous piessuie 01 nutation horn tin1 hand-
liny ot tools, etc »S'<r Iniiinosis
CallUS. — lionv matonal throun out IM>-
twccu and around the evds of a tract uied bone
e healing piocess, especially marked if
the fiiutuic h.is been badly set *SV<" FKACTUURS
(Ptoifw of Repair) , LABOUR, PUOLONOFD (7V/y*c
Defw mi tte*>t /' ? nrture)
Calomel. — Mriuuoub ohlondc Xee MER-
< ui<\ flee alw ('noLAdodUKs , ECLAMPSIA , Pu \n-
MACOIXKiY , PlUMCRiniMi , S\1'111IIS, etc
Calor Mordax. — The <b\, binning
])nn^,(>nt heat ot the skin, as noted Irv the
obser\(>i's hand, in pneumonia, malana, and
scailatina .SVr PM-UMOMA, (1riMr\i (Clinual
Fititwn)
Calorie or Calory. -The (on\ mtion.il
unit of ([U.intity oi licat the small (.done is
the amount ofr he.it netessaiN to laise 1 iriam
of \\.itc1! I1" (' (01 horn l.V to 16 (' ) , the laigo
caloiic is that ici|iinul to laise I kilof>iam of
\\atei 1° (1 , and is equnalent to 3 ()7 Bntish
tlieimal units (the ISThU -^<niantit\ ot lie.it
ne(essai\ to t use 1 Ib ot \\atei 1 F) »SVf
PinsioiiM^, Tissi iis ( l/jisf u/m) , I'lnsioifM,^,
F<M)i> AND DH.FSIION (Enmjy Vahn)
Calprigen. — A toim oi -as sto\o
((Jeoij'L'V), cont.iuun>; }>ij)es «in\e^inu .1 supply
of flesh an
CalOtrOpiS. — Mnd<t>, 01 the diied loot
of fWofrn;ifs jttwtiH, othcial in India and
Rntish Colonies, used in doses ot 3 to 10 <:is
as a tonic, and oi .)() to fiO j;is as an emetic ,
the TuultiHi t'lilotHqn** has a dose ol \ to
1 11 di , it is employed foi tin tieatment ot
elephantiasis (e\teinall}), and ot s\phihs and
iheum.itism
Calumbse Radix. >svr
PlTAKVA(M)UJ(f\ , PlthMMIIIUMT, ^U \SS1A , ett . -
Cafumlm Root is .1 typical \ejfetable luttei
Its chief constituents aic--(l) (!ti/uintnn, u
noutial bittei pimuple , (2) /Minnie, an
alkiloid, (3) (Plumbic Add, (1) Stanh The
mttw jnimtiilc m.iy be looked upon as a
mixtuie of the fiiht thiee It contains no
tannin, and its picpaiations (an theiefoie be
preset ilx.nl AMth salts of non
Pitjxitntions — 1 Jnfusum Calumbte Dmt —
J - 1 07 2 Lujuoi Caluinbjo Conccntratus
Dow — \-l di .J Tuutuia ('alumb.e Dose —
1-1 di "
(1alumba is .'id ministered beioie food as a
stomadnc tonic, either alone 01, moie usually,
in combination \\ith othei diuujh, such as non,
aiscMnc, and nu\ vomita It stimulates the
appetite, and increases the flo>v of saliva and
Castile juice It is useful in cases of A\eak
pumaiy digestion, in geneial debility, in
an.t'inia, and dunng con \alesc enee fiom acut(v
diseases The infusion has been gi\en as a
icctal injection to destroy thread -\\onns, but
quassia is moie geneially employed for this
pin pose
CALVAKIA
Calvarla.— The top part or loof of the
skull, the portion lying above the occipital
protuberance, the oibits, and the ears , calvauuin
is a modern foim of the \void See Avi'inio-
POl 0«Y.
CalvitieS.— Baldness ,SVg Ai OPKH A
«SVe (1ALCIUM, CllLCHIINh
Chlorinata) , SuJ.ruuit (Colt
PlIARHACOrX)GY , Pl<ESCI{IUIN(.
ge is a gum rosin,
acting <is a powerful pmgati\c (diastu hydia-
gogue), and seldom used (on account oi its
griping effects), unless in the foim of the
Pdula Camfjoi/ut Comjiowta (\\hiih contains
also liaibados aloes) (Jamhoge ( ontains a bi ight
yellow resin (gaiubogu acid) and a soluble gum ,
the dose is ^ to 2 grs , and oi the Compound
Pill, 4 to 8 gis O(tni?*fMjm Indua, 01 Indian
Gamboge, is found in the Indian and Colonial
Addendum (1900) to the British Phainuuopaia ,
it is got fiom (Jamma nwrelta (the Hiitish
drug is fiom Gamma Jfanbuiu), and it has
the same action and dose (J to 2 grs )
Cameron's Septic Tank. »sw
SfcWAdK AM) DllAIVAtiF (StVHtyr Diyjovt')
CamiSOle. — A sti ait -jacket 01 strait-
uaistcoat, used in the management of the
insane
Cam p Fever. *sve T\ MILS FEV » K
Camphene. -One of the series ot solid
hydi oeai bons, i ailed terjienei (t-](,Hl4l), foimed
ailifitially or occ lining natuially (in some oils)
Camphora. A&? APIIRODISTVCS, PHAK-
MACOUH,\ , pREtiTRiniMi , etc — Ctsmjihrmi is
obtained fiom Cmnamomiun ntmjihoin^ the
tamphoi laurel, found in the K.ist Indies, China,
and .Japan It is m the foim oi (olouiless
ciystallme masses, with \ powerful chaiactciistie
(xltiur and a bittci, pungent taste It is soluble
1 in 700 oi \\ater, 1 in 2 of oil of tuipentme,
1 in 4 of olive oil, and leadily in milk, ethei,
alcohol, and ehlorofoim When mixed with
chloral, carbolic acid, in thjmol it hums a thick
liquid Aw— 2-5 gis
riefxiiattonv — 1 A<nia Camphoi.e. Dote —
1-2 oz 2 Lnnmentuiu Camphoice (Cam-
phorated Oil) 3 Limmentum Camphoi.e
Arnmoniatuai (Compound Liniment of Camphoi)
4 Spintus C'amphoi.u Dote — 5-20 m 5
Tmctuia Camphoi.e ComposiU (tee OPIUM)
Liniments containing eamphoi are l.ngely
employed in chronic iheumatism, iKMiralgia,
lumbago, sciatica, and m slight chest tioubles
The benefit derived is piobably due m most eases
to its slight countei-imtant effect, in some to
its local anaesthetic action A mixture oi
eamphoi and carbolic acid dioppcd into a tooth
\\ill frequently rehe\e toothache Internally,
VOL n
eamphoi is used as a carminative and anti-
spasmodic, especially in neurotic subjects A
few diops of the spirit of camphor in milk or on
sugar taken eseiy hali-hout Mill m some persona
arrest a cold in the head it taken in the initial
stages It has been used in choleia because
oi its mild antiseptic action Lastly, it has
been iccommended in thi eatcyied ( .mliac failure,
gnen hypodeimically dis'-ohed in rectified
spmt (1 in 5)
Campylorrhachls. — Distortion or
mi \iituif* ot the spine, especially \vhcn of a
tiiatologi tl amount The same loot (*»/**
Tri'Ao?, (looked) is contained in campy lochfn us
(diitoitwl hand), ramjiyfrnt/umit (ciookcd nose),
and HiiH]>y/i)wlu\ (i rooked leg)
Canada. >SVe BALNMJI or^ (Antetica and
CunaJa)
Canal Boats.— Any \essel, not a ship,
used ioi the con \ chance of goods along a canal
("anymer, inland na\igation, lake, or \vater,
being \vithm the luxly oi i county, \\hcther it
is 01 is not \\itlnn the ebb and flo\v of the
tide"), ho\\c^ei it m ty be propelled All such
boats must (in England and Wales) be legisteied
Mith the Loial Authoiity it used as a dwelling-
house KeguLitions foi the h\giene of canal
boats, and foi the management oi cases of illness
occumng on boaid, are found in the Canal Boats
A<tsof lS77and 1881
Canal, Cloquet'S.— The hyaloid canal
in the Mtieous humoui, through \thich, m the
antenatal state, the hyaloid alter} passes to the
lens
Canal, Genital. >SVr GENERATION,
FhMAIK OltbANS OF, LABOUR, PRLriPIIAlE AND
PicoioNdhD , LAHOUH, INJURIES TO INK (IhNER-
AIINF OlW.ANS , ItlfcKU.S, MALFORMATIONS OF TUB ,
VAlilN\, DlSOKDliltS OF
Canal, Haversian. fr? PH^SIOLCX.Y,
TISSULS (]lwu)
CanaliCilli. *NVe LAC m\\ MAI, A IT A HAT us,
l)is> \SFS <>r
Canalization. (1) The con\eision
(dming labom) oi the uteio-\agmo-vuhai tia<t
into a continuous canal of piacticall} ecpial
c.ihbie tor the tiansit of the infant .See
L\IJOUK, SIA<,FS AND DUKATIOV (2) The foima-
tiou of < hannels, c <j blood-vessels Vnd (3) a
method of diaming \vounds
Canal Of Nuck. Me HERNIA (Oblique
Iwfunml)
Canals, Sem icl rcu lar. *sw Pm sio-
WK,^, SENSES (Inter mil Ear), PinsioLcxiv,
NERVOUN S^MLM (tiemi<ncular Canals) , \ ERTKJO
(tWmf'tf'i Dn>t<t^)
Canary Islands. >SVe THERAPEUTICS,
HbALTH RESORTS (hlawls qftfte Smith Atlantic)
50
CANCELLOUS
Cancel lOUSi—Tissucs (e q bone) having
a spongy or lattice-like stiucture are called
cancellow See I'm siouxn , TISSUES (Bone)
Cancer. See TUMOUR (Epithelial Gt oup)
See also ADRENALIN , APPENDIX VERMIFORMIS
(Cancerouv Diteave) , APPLHIK (Lot* of) ,
BLADDER, LNJURIFS ANM> DISEASES (Tumourt) ,
MONK, DISEASES OK (Tumours) , BUAIN, TUMOURS
OF (Carcmomata) , CACUKXIA (Cancer out) ,
COLON, DISEASES OK (Nerowlaty Memfaanobt
Colitis), GALL-liLADDfcR (TuWOUtS Of), (jALL-
BLADDKR \ND BILE Duns, DISEASES or (Turnout*
of the /hie Duct*) , Huttum , KIP- JOINT,
DISEASES OK (Turnouts tn Jieymn of llip) , IN-
TESTINES, DISEYHES OK (Malu/iuint Disease),
KIDXK\, SURGICAL AFFECTIONS OK (Turnouts) ,
LABOUR, PRECIPITATE AND PROLONGED (Fault* in
the Noft rassai/ev, Camn of the Cenm) , LIVER
(Pruhepatitiv, Stttnulaiy), MAUMAUA ULAND,
DISEASES OK (Cat cnionuita) , MEDIASTINUM
(Mediatorial antl other Intra-Thoractc f/Hwf/ts),
MiCRo-OiidAMsMs (Camei Jiodie*) , (KsoPUAc.us
(Growths, A/alif/ntint) , ORBII, DISE\SES of HIE,
PANCREAS, DISEASES OK (Main/mint Dilates) ,
PERITONKUM, TUMOURS OF (Malujnant) , PREG-
NANCY, AKFErilONS OK (iKNBKATI\h ORGANS
(Cancer of ' Utnv\) , RADIUM, RECTUM, DISEASES
OF THE ((JtlHCfr) , SlOM\fH AND DUODENUM,
DISEASES OK (Cancel), TUMOURS (Chloioina) ,
TUMOURS (Camnoma), I TERUN, MALIGNANT
TUMOURS CM , VAJ.INA, DISORDFRS 01 (Cai-
cinoma) , X-RA\s (Cancet and Nanonta)
lau^htei,
usually hysterical in n.ituie «SVe H^STEIUA
Cancroin. — A ioxinc found in camno-
uuvtous growths, and used subcutanoously ior
the treatment ot cancel (Ad<imkiei<<ic~.)
Cancru m Oris. $<* s TOM \i 1 1 is (a,i //-
gtenoui) »SVf also CA\(.RFNE (Inteittve) ,
MEASLES (Complication*, Nomi) , TYPHOID FEV^R
(Complication*)
Candela. — A bougie, \vn\ 01 niedicated
Candles. — Feeble illuminating agents,
made ot tallo\\, stearin, paiaflin, va\, sp(U-
maeeti, and compositions! , thoy have piactically
no bad cftect on health, "one candle powei "
is the light given by a speim candle burning at
the rate ot 120 grs pei horn >SVe VENTILATION
AND WARMING
Cane Sugar.
AND DIGESTION (Cai
>sw
FOOD
CanitieS. — Gieyness, piemature or
senile See NAILS, AFFECTIONS OK (Canihet)
SKIN, PIGMENTARY AKI-ECTIONS OF (Piymentaiy
Anomalies of Jlaii)
Cannabls Indica.
ment), DRUG KRL PTIONS (CannabisJndica) , PHAR
MACOLOGY, PRESCRIBING, TOXICOLOGY (Indian
Hemp) — Cannalns Indica is derived from the
ducd flowering or fruiting tops of Indian hemp
— C anna bis mttva It contains an aetivc prin-
ciple, Cannabmon, two .ilkaloids, a glncoside,
and a large amount of resin kno\vn as chuirus
In India the plant is eaten 01 smoked for its
intoxicating efteets " llasclnsch " is a eonfec-
tion of the diug, "Bhang" a dunk made fiom
the po\\ deied tops. Pi epaiatwn 9— 1 Extraetuin
1ann.ibis Tnduje Dn*>e — J-l gr 2 Timtiua
'annabis Indiccu Dote — 5-15 m Is contained
n Tinctina Chloiofornu et Moijthince Ctnnjiosrta
The action ot this diug is fust of all stimulating
to the central nei\ous system, causing an intoxi-
cation analogous to th.it pioduu'd by alcohol
Liaigei doses are followed by lassitude-, musculai
\\eakness, and eventually sleep It does not
cause constipation, noi dors it dimmish the
secretion ot mine , and ioi these leasons it has
>een recommended as .in anodyne and hypnotic
n discMsc's in which opium is unsuitable, such
as lo(ouiotoi ataxia, neuialgia, gastialgia, and
c^pilepsy The piepaiations of cannabis indua,
IIOWCMCI, are umeliablc, and the action of the
diug \anes gieatly in diilerc'iit mdmduals In
some even a model ate dose causes gie.it ceiebial
excitement and violent \\akmg delirium It h.u»
now to a gieat extent diopped out oi use The
tincture is difficult to picscnbe elegantly, because
ot the piesence ot the lesm \\hu h ispiecipitated
b) \\ater
Cannea. &e BALNE<3Lo<n (India,
Ceylon)
Cannes- ^ TiihRAphuiirs, iik\Liif
RFSORIS (Rinteia)
Cannibalism. &e KIHNOLOC^
Can nil la. — A tube, usually containing a
piinc tuimg niHtiumcnt (tioeai), mtiodiued into
a cystic tumoui or body ca\it\ to allo\\ the
CM ape of fluid , it may aKo be usud foi the
admission of an (.is m ti ac heotomj ), toi cm ing
stenosis of a canal, i>i fo> canning a plug to the
postenor naies (liellouji cannula)
Can Or. — A metallic tinkling sound heard
on auscultation
Can quoin's Paste.— A paste consist-
ing of /me chlonde, /me oxide, and wheat flour ,
caustic m action
CantharldeS. tee DERMMTHS TRAU-
MAIICA BT VENENAI-A, NEPHRITIS (Etiology),
PiiARM/tooLO(j\ , PRESCRIBING, TOXICOLOG\
(Abort ifacientit) — Canthatis or Spanish Fly is
derued horn the dried and powdered beetle,
Canthariv vesicatoria, collected chiefly m Hungary
and Russia The powdei is gieyish bro\vn with
shining green particles m it, and has a stiong,
disagreeable odoui The chief constituents ai e
Canthartdin, the active principle , and two oils,
CANTHARIDES
51
ono volatile, giving the smell, and the other
green, yielding the coloui
PrcjMirationi—\ Tmctura Canthandis Dme
— 5-15 in , if frequently repeated, 2 - 5 ni
2 Acetuni Canthaiidis tfttent/th —1 in 10
3 Unguentum (Unthandis Xtiemjtfi — 1 in 10
4 Kmplastium Oanthciiidis Ntnrwith — 1 in 3
5 EmpLibtruiu Calefaucns Ntrent/t/i —1 in 25
6 Liquor Kpispastic us Hit f with- 1 in 2 7. Col-
lodmin Vesicans Mteiujth— 1 in 2
Canthandes is chiefly employed exteinally as
& eoimter-nritant It is very ichable, althoimh
somewhat slow in action It is applied ovei all
sorts of inflammatory and painful conditions
It should nevei be used in patients sufleimg
f loin kidney disease, in debilitated persons, or
ohildion, as it may be absoibcd by the skin and
cause mteinal nutation, paiticulaily ot the
kidneys It should be applied o\ci a small area
at a time When the plastei is used it should
be removed as soon as the bhstei has iisen,
because of the n&k of absorption Canihandes
is contained m many mixtuies the object of
which is to stimulate the growth of the ban Jt
is haidly ever given internally, but small doses
of the tincture have pio\ed beneficial in chiomc
jjoet It has a wide leputation among the
laity as an aphi (xhsi.u , but this action, being
due solely to dneit iint.itinti of the gcmt.il
organs, can only be accomplished by the admin-
istiation of toxu doses
Ca.nthOpla.Sty. — The leconsti notion of
the canthus of the eye or any plastic operation
in its neighbomhood *SW E\bLii>s, AI-FEITIONS
OF (»S/w?//j of the Oiln<ul<m* J/ttW**) Canthor-
raphy is the opei.ition of suturing the canthus,
while cantkotomi/ is simple division of it (The
cant/mi, is the angle, outei 01 inner wheie the
upper and lowei evehds meet)
CaOlltChOUC. — Indiaiuhhci, 01 iubbei ,
obtained by diymg the milky juice of Htvtti
biavlwnsib and othei tiopical plants The
oftuial piepaiatum is fat/tun Ctwutihow (made
by dissolving 1 o/ of mdiaiubbei in shreds
in 10 fl o/ of benzol and 10 fl o/ of caibon
bisulphide), used in the piepaiation of Charta
Sinapis Vulcanised indiarubbcr is a combina-
tion of sulphur with caout( houc
Capacity. — Tcstamentaiy capacity is the
state of mental health necessary foi making a
will which shall be \ahd ^SVe CIVIL INCAPACITY
Cape Town. »SV<« TiihKAi'EUTirs, HEM/MI
RESOUIH (South Aft no)
Capillaries, Diseases of.
CONGENITAL AJSGIOM\ —
Iltstolotiy 51
Clinical Hittfny 52
Diaynobis 52
Treatment 5*2
NON-CONQENITAL CAriLLAH\ ANGIOMA 53
THB most common and nnpoitant affection in-
volving capillaries is .uigioma This may occur
in any part of the l>ody, but is most fiequent in
the skin and subcutaneous texture, so that we
may confine oui desciiption to that region
Piohahly the most elastic and compiehensive
classihcation of the angiomatti is the anatomical
(Tapillaiy = Telangiectasis , Erectile
I tumour , Cavernous tumour
Angioma- Venous = Phlebectasis
Cn sold ancurysm
phiitu = Lymphangioma
- e
I Arterial
\L\ mp
tiMjwiiiti is best considered under t%o
heads the < ougenital and the non-congenital
I CoN(.FXir\i AN MOM A XAVUS-— may be
sulxj'vided pathologically or clinically In the
one MCV\ \>e have the simple, venous, and
aiteiial, in the other the ( utaneous, subcuta-
neous, and mi\t>d We shall presently see the
value of these distinctions
I[i\tol<><iy — On section the simple noivus
presents the appearance of a finely leticulated
sponge with nnperiettly maiked lobulation
The lamina; are thin and iibious, and lined by
epithelium continuous \\ith that of the blood-
vessels It may or may not be surrounded by
a capsule A najvus giows in tvio ways — in-
tunsic or eUiinsu If its gio^th is intunsic,
,ind cspc( lally if it be slow, it pushes paits aside
and foims a capsule Hut a n.xjvus often in-
vades its smroundiugs like an inflammation or
a malignant turnout What is the influence
\\hich mctamoiphosed capillanes can thus exei-
<ise on their neighbours it is difhcult to con-
ceive Hut I ha\e seen one glow by invasion
m a ^eek 01 two finm the si/e of a shilling till
it occupied halt a baby's face and head, o< t luded
its eye, and deformed its eai In such cases,
ami m so fai as a ihevus may occupy the skin,
theie is no capsule, a point ot importance in
connection \\ith treatment
In tiie vasculai aiiangemeiits theic aie many
modifications Thus it is not unusual for a
n.eMis to pulsate fiom the beginning, when
tortuous and dilated aitenoles may be dissected
out, although there is ceitamly no form which
in the least icsemblcs histologu ally the cirsoid
anouiwu, 01 even perhaps the aneuiysm by
anastomosis of the adult Smnlaily enlarge-
ment of venous iodides may cntei largely into
the composition of a mevus — so laigely, indeed,
as gieatly to mask its oiigmal c«i|Jillaiy diameter
If you put on the stietch skin which is occupied
by a small and recent nwvus, you will display a
most beautiful network of visible capillanes
often m pai al lei rows, with pcihaps a winding
aitenole 01 dilated \ein Fiom this simple
dilatation, and it may be multiplication of
capillaiies, piesumably anse by pressure on the
inteivasculai stiucturcs and foimation of fresh
intercommunications the appeal ances already
described
52
CAPILLAIUEH, DISEASES OF
Clinical History — Theie may be seen a slight
stain at birth, and as a rule a nawus declares
itself, if at all, within a fortnight It is veiy
variable in its rate of growth Its most lapid
rate is geneially eaily After tho fhst few
months it tends to glow with the child There
is a great tendency to spontaneous disappear-
ance More than half of the subcutaneous and
mixed varieties ate naturally cuied The cuta-
neous vanety, tho port- wine stain, is, however,
prone to persist through life The subcutaneous
and mixed varieties ai e likely to persist in pro-
poition as they .ire associated with or acquire
arterial, venous, or degeneiative changes
The natural cuie is brought about by a fihious
atrophy piobably inflammatory in chaiactet, and
certainly capable of being excited by inflamma-
tory causes to which a lucvus is veiy seiisiti\e
This process may be modified in various ways
In the atrophy portions of the tumour may be
blocked off and form cysts The alteied blood
in them is more thin and wateiy, and the
deposit of fibnn on their nails less copious than
in hiematocele orextiavasation cysts I am not
sure that these cysts are always bloiked-oft
blood-vessels, because I have found them purely
serous, even among others containing altered
blood But piobably the most frequent de-
geneiation is fibrous The n.evus is cured, but
involution of the hbious tissue fails I have not
met with a sai coma tons change in nteviis uncon-
nected with the pigmented mole
DuH/nosiv — The symptoms need only be con-
sideied m so far as they aid diagnosis The
mixed variety of mcvus may be mistaken foi
memngoeelc and spma bihda, the subcutaneous
or degenerated for fatty, cystic, and sarcomatous
tumours
The most important diagnostic difficulty is
with menmgoccle, which 1 have seveial times
had sent me for n.evus, fiom then similanty
in appearance, consistence, and compi essibility
The mere fact that the growth occuis in the
middle line should put one on guard In that
lino only lies the ditlnulty The menmgoccle
is seen nowhere else Cohesion to the bone
calls for additional caie A iicuvus may cohere,
but if on compiession a neck -like connection,
and still better if the contoui of an ouficc in
the skull can be felt, a veiy important dis-
tinction is made out If it be not absolutely
congenital it is muvns If an mttoduccd needle
be felt free m a cavity, and clear fluid with
cerebial characters be removed, no doubt
remains The same considerations apply to
spma bmda, which is also sometimes mistaken
The sarcoma as it occurs in infants is apt to
be very vascular, and looks like a mcvus The
congenital, or neaily congenital origin, the shape,
compressibility, consistence, and situation serve
to distinguish a najvus from it and other
tumours
Treatment — No nsevus in a child should be
submitted to treatment unless it be clcaily
increasing, or likely to do harm from its
situation or condition Many mcvi disappear,
and Nature's result is as good as any Tho
reason for treatment is not usually danger,
but disfigurement The danger comes irom
wound or ulcer ation It is therefore slight
If the tumour be stationary, not ulcerated,
and not doing harm, it is best to \\.ut I
leave out of account harmless placebos such
as collodion or gentle pressure
The methods of ticatmcnt are very numerous
They may bo arranged as —
I Exteinal escharotus or irritants, 2 Sub-
cutaneous escharotics or imtants, 3 Ligature ,
4 Excision
1 There aie three conditions under which
this form of ttcatmeut should IKS adopted —
(a) A tiny iitUVUH, with radiating vessels, is
common on the nose or ihcek It generally
goes away, but sometimes incieases It may
be so easily destroyed by a needle with nitric
acid, by a heated point, or the negative electro-
lysis needle, that it ought to be cured without
delay.
(ft) Flat iifcvi of the skin on the coveied parts
of the body may be well tieatcd by Hiehardson's
sodium ethylate It leaves little scarring
(< ) Our only method of treating the poit-wme
stain of the f.icc without leaving a worse mark
is by the long-continued application of irritants
Squire's knife, multiple puncture, and all other
means have w ith me been very disappointing
Cure by means of an irritative deimatitis is
not certain, and requires much patience and
perseverance , but it does no harm, and is
sometimes successful I think strong iodine
is the most manageable irritant
2 I ha\e cntnely given up the subcutaneous
injection of such substances as tannin, por-
chlonde of non, and carbolic acid, as well as
the subcutaneous use oi the heated \virc, m
favoui of electrolysis All of them act in the
same way, MX by the destruction of tcxtuie
But by electrolysis the destroying agents aie
introduced in infinitesimal division, and there-
tore aie much more under the surgeon's contiol
than by any other method Moi cover, the
dangei of subcutaneous injection without a
temporaiy ligatuie has been frequently demon-
stiatcd by the sudden death of the patient
There are one or two laie cases m which
the platinum wne heated by electricity sub-
cutaneously might be used, but almost in-
variably for subcutaneous use electrolysis is
the best agent
Tho mode of using it and its value will be
considered under the article "Electrolysis"
Meantime it suthces to say that for mixed
and subcutaneous ii«evi on exposed parts of the
body, and for ntovi clsewheie, which are very
large or otherwise inoperable, electrolysis is
safe and certain, although slow
CAPILLARIES, DISEASES OF
53
Lujatui e — I think there is scarcely any case
in winch this method is no\\ requited
Excision — The advantages of excision over
electrolysis are its greater ceitainty and rapidity
The former is slight, because excision may fail,
and clectrol)sis rarely docs so The lattei is
undoubted and considerable Kxeisum requires
only one opciation, electrolysis usually moic
In c«ises, theieioie, where a scar is of no
importance, and the bize and relations of the
tumour are not such as to make the operation
dangerous, excision is preferable to anj other
method
II NoN -CONGENITAL (JAl'ILL\H\ ANMOMA IS
in the simple foim Tare, most usual in mt« inai
organs, of exceedingly slow growth, but \\ith
little tendency to retrogression More common
arc the venous and arterial These three
varieties correspond to the \aneties of n»evus
histologic ally They present, as above seen,
differences from minus clinically, and to the
lasi belongs that rare affection called osteo-
aneurysm A fourth variety has no analogv
among congenital \aricties, and to it the name
ancui}sm by anastomosis may piopeily be
given It consists of mctamcu phoscd capillaries
in which large cavities aie connected with
dilated arteries on the one hand and dilated
veins on the othei Many of the characters
of alter 10- venous •ineuiysm are here to be seen
mingled \\ith others more pioper to a capillary
or venous tumour
In treatment we aie here also restruted to
electrolysis and excision The foimcr most
certainly should be tried hist, as it is piactually
without tisk, and holds out a iau piospect ot
success These varieties, and especially the
aneurysm bv anastomosis, are, however, much
rnoie resistant than congenital forms When
electiolysis fails the propriety ot itternpting
excision must be deter mined m each c.ise by
the risk It is alwa\s to be remembered
that these tumours ha\c little tendency to
shoiten life, and that only the tumble they
give, chiefly by disfiguicincnt, pulsation, and
murmur, warrants niter iereme Operation by
excision is always seuous, oitou impossible
The consideration of the other foims of
angioma limited in oiigm to the aitcrics, to
the veins, and to the lymphatics, will be iound
in the articles on these subjects and on
" Tumours "
Capillary Bronchitis. #" BRONCHI,
BuoNrmra (ChihJteti)
Capital, Life. ^ Lu-h (1Am VL
CapOtS. — Or etins , pi obably a corr uption
of CAGOTS (y v )
Capri. tiee THERAPEUTICS, HEALTH KE-
aoiiTS (Italy, South)
CapriC Acid. — A monobasic, fatty acid
(CjuHjoOj) occurring in goat's milk , it belongs
to the acetic scries (formic, acetic, propiomc,
etc) Cajnnic ftcuf (C^Hj ,O2) «md Capiylu
(tcid (C8FTlfO2) arc other acids of the same
series Each has its corresponding aldehyde
(C^H^O, C(1H,,(), C8HU,0) and ether Ctij*iti,
ea/notn, and taptylin are fatty substances found
111 goat's butter
•CapSiCi FrUGtUS.— The hint (dried)
of (JapHCKHi, nmunium , pod pepper When
powdered it is Known as red pepper The dose
is £ to 1 gr There are two official prepara-
tions the Tinctmn (Jajtsiti (dose, 5 to 15 m ),
and the Urt'iutntum (tynm (which resembles
Smcdlcv's (hillie paste) It contains (along
with other things) an acid substance (capsaicin),
a volatile alkaloid (capsicme), a \olatile oil, and
a resin Externally, it is used (in the form of
the ointment) as a counter-irritant in inflam-
matory and painful affections (pleurisy, sciatica),
while1 inter nail} it acts as a stomachic
Capsule, Internal. >sw
PHYSIOLOM OF, PmsioLoc/k, NEHXOUS
(Cetelrrwn)
CapSUleS. — Small gelatine cases, contain-
ing drugs (usually nauseous), for convenience in
swallowing
CapSUlitiS. *SVv
CVrutArr, LKNS, Cmsr
CapSUlotOtny. — (1) incision of the
capsule of the kidney iis performed for l^nght's
disease ( I'ttle DPC-M'SUIAIION ) (2) Incision of
the capsule of the crystalline lens
Caput. — The head (or origin) of a muscle,
or ot a bone, or ot a pirt of the intestine
("caput coh"), etc (Yule mh't )
Caput MedUSSe.— In the new-born
infant the cireum- umbilical cutaneous veins
aie apt to be dilated and tortuous, on account
of stasis m the port.il \cm , the appearance
thus produced is called the* Cajnit Metluw
tfee LUFII, DISEASES or (Mtnlnl Anatomy,
Andttomowi))
Caput Succedaneum.— The sott
swelling (serous infiltration) which forms over
the presenting part (vertex, face, breech,
shoulder) of the infant in labour *SVr LABOUU,
STVC.KS AM> DUKAIION (»SVrow/ »SVfff/rf Pheiw-
mena) , Lvuouu, DIAC.NOSIS AND MEC'IIANTSM
(}reitei, /Twf, Show, (.uuJ Ilrecch Ptesentations) ,
LABOUR, PHKCUMTVIB AND Pi«)rx)NCiKD (Con-
tracted Pelvis)
CarantfldSB.— Horse mackerel, poison-
ous hsh >S'e? SNAKE- BUBS AND POISONOUS
CarateS. — A South American skin disease,
54
CARAT^S
characterised by the occurrence of coloured
patches on tho f.icc (the name signifies " look
at tho face"), toe PINTA
Caraway Fruit. Net CAHUI Fuunus
Ca.rba.lite. -A im\tm<» containing chai-
coal, used as a filter for watei
Carbamide. - UK* (NH2 co NH2), the
chamidc of c.ubomc .icid, the hist organic com-
pound prepared by synthesis from moigamc
sources Catbamir acid is c.ub.imide with
hydioxyl in place of anudogcn (NH, CO OH),
and it foiniB carbimtttev (e<i .immoiiium carb-
amate, and ethyl caibamate 01 iut,tht.me)
CarbazotlC Acid. — PH nc acid 01
trimtrophenol
Carbide. — A compound foimcd by the
union of carbon with anothei clement, usually a
metal, <•*/ calcium carbide (CaC^,).
CarbO. See alw BISUM-IUDE OP CARBON ,
SKIN, PIGMENTARY Ai-FhOTioNs (//air) — Cait'O
Lti/ni, wood charcoal, is the only otlmal foim of
carbon It is a black, odourless, and tasteless
powder Dose— GO to 120 grs
Extcinally, charcoal has a considerable icpu-
tation as an application for foul ulcers and soies
It should be used in the dry state, and frequently
icwwed, as the dischaige soon moistens it and
destrovs its oxidising poweis It is sometimes
employed as a tooth powder Intel nally, it
has been given as a powder, as lo/enges, and
as biscuits to chock gastric fermentation It
appears to have a special atti action foi alkal-
oids, and has been recommended in laige doses
as an antidote in opium poisoning
Carbohydrates. flee DIABETES MEI,
LITUS (Phyuolotjiutl Conudetatwn^) , DIEI
(Nvtt itive Constituents of Food) , DIGESTION AND
METABOLISM (Carl>ohy<hate*) , ENXYMES (Jfydio-
li*m</) , OBESITY (Dietetii Tnntment) , PIIYSTO-
WGY, FOOD AND DIGESTION (Ft tail, Heat J'ro-
duction, (»enet al Metabolism, antt Dtetetu.*)
Carbohydraturia.— The picscncc of
carbohydiates (sugais) in the urine
CarbOliC Acid. See «/w ASEPTIC
TREATMENT, ANTISEPTIC] SURGERY , DRUG Euur-
IIONS (Tar), GANGRENE (Vanities, Carbolic
Aild), PlIAKVUOOLOGY , PKUU'KIBING , TETANUS
(Jiauelh's Method o/ Treatment) , Tnxicoixxii
(C'oriwiiw, Acid*) — Carbohc And, 01 /V/e/io/,
is made from coal tar by distillation and puri-
fication It consists of colouilcss acicular
crystals which are very Irydioscopic, and be-
come liquid on the addition of 6 per cent
of watei It melts into an oily liquid at
91 5° F. It is soluble 1 in 14 of water,
and freely in alcohol and oils Dost — 1-3 grs
— Prepatations—l Aciduin Caibolicum Lique-
faetinn. Contains 10 per cent of water Dose —
1-3 m 2. Unguentum Acidi Caibolici 3
Glyceimuni Acidi Carbohci, 1 gr of phenol in
5m 4 Stippositoria Audi Carbolici , 1 gr m
each 5 Trochiscus Audi Caibolici , 1 gr in
each Crude caibolic acid is used very largely
as a disinfectant and deodorant foi diams, bed-
pans, and so on The punhcd foi in m various
dilutions is the most generally lehable antiseptic
we possess, and is employed almost unnei sally
for surgical purposes A 1 in 20 solution is
used foi purifying the surgeon's hands, the skin
of the patient, etc Instruments and dressings
may be kept m a I in 20 01 \veakei solution till
tequned Dressings for wounds ate soaked in a
solution of 1 in 40 01 1 in 60 , but caio must be
taken that too laigc a dressing is not applied,
on account of the risk of absorption which takes
place \eiy leadily through the skin Fingers and
toes should nevei betieated by caibolic fomenta-
tions, as numeious cases of gangienc following
its use have been lepmtcd Pure caibolit ncul
is a veiy efficient antiseptic foi application to
foul soi ea, uheiated surfaces, abscess cavities,
tuberculous sinuses, eti A vaginal done ho of
1 m 40 01 1 in 60 caibolic is \eiy serviceable in
the tie.ituicnt of pueipeial sapia'imc condi-
tions Itchmess of the skin in seal let fever is
relieved by sponging w ith a 2 per cent lotion of
carbolic The ointment 01 a lotion is iccom-
mended for various skin diseases \\hen a com-
bined antiseptic and anaesthetic action .ire
icquircd (llycerinum Acidi Caibolici is veiy
efficient in destioying the fungus of tinea ton-
sui.ins A small piece of cotton-wool soaked
in pure carboli* , placed in a canons tooth,
i eh eves toothache The glyceiinum is a useful
application for aphthous or uheiative stomat-
itis It must be used caiefully, as it is very
powciful It is also benefici.il in septic condi-
tions of the thioat 01 tonsils, foi v\huh purposes
it may he applied dnectly undiluted, 01 cm-
ployed as a gargle or spiay in the stiength of
i 20 m of the gljcermum to the ounce of watei
> Internally, call >ohc, and has been advocated
foi dyspepsia with flatulence, diariha'a, typhoid
fever, and cholcia , but its value in these dis-
eases is veiy doubtful, on account oi the dilution
oftected by the gastric and intestinal contents
Large doses of a 2 per tout solution adminis-
tered hypodermically have given good icsults
in some cases of tetanus Its use in phthisis,
internally, by inhalation, and as an mtra-
trachcal injection, has been abandoned It is
stiongly advocated, however, as an inhalation in
w hooping-cough
Swlii MalphocarlolcH has been lecommended
to contzol gastnc fermentation in doses of from
5 to 15 gis , but it has probably no beneficial
action
Zinti SulpJtocatlofas may be used externally
as an antiseptic for the same purposes as
carbolic acid, but it has no special advantages
CarbOlurla. Xee CARBOLIC ACID, URINE,
PATHOLOGICAL CiiANOhh IN (Colrwr, Drugs in)
Carbon Bisulphide, foe BISULPHIDE
OK CARIION «SVe a/so AMBLYOPIA (Tnnt) , Toxi-
COIXM.Y (Organtc Poiwm, Cotton JJnutphtde) ,
TRADES, PAMIERUUS (/inulp/ude of Cat ton)
Carbonic Acid. See AIR, F:\AMINA-
TION OK (Cartonit And, (hound AD) i BREATH
(Chemical E/amination) , fiiniKRi, EPIDEMIC
(Analysts of Nynifttom*, Refutation) , LAUOUK,
Piniuoixxi\ or (Cauva at Layout), MEDH INL,
FoRhNHio (Death from- Aythi/jia) , MINFUAL
WAIERS (Mutinied Naltne , Em thy rind Cal-
careous), PiiYHiorxMiY, BIOOD (f/fise») , PH \3io-
LO<.\, KXCRLUOK (Unne), PREGNANT, Pmsio-
ixxn (C/iaw/ei in Reynration) , SIOMACH AND
DUODENUM, DISEVSBS ((lennal tiyHijrfoniatolor/y,
Jflatultnre), TnxiroixxA (tourrms/'oisons^'aiAon
Dionde)
Carbonic Oxide. *«' Asi>m\u '
(C'dMvs) , Mhim IM, FoitiiNsic (/h'at/t from
Asphyjui, Cm ton u Oxidi) , PJIWOLOM, Bioon
(Carton - mono tide - ha mo(/fooin) , Toxicoi O<,Y
oikong, Carton Afonoxide)
Carbonyl Chloride. -An
^as (CO, CM,) tnnncrl by tlic rlecoinpositiuu of
chloiofunn in the pii'scmo of huiimifi conl gas
01 oil, phns^oii Kre AM.SIIILMA, (JLNFRKL
I '11 \ bioixxn (( 'A/Mi ofoi m )
Carbuncle. Nte AMIIHAV, JioiJh AND
(Cotfiunrtt), DIXHEII^ MEILUL«>
fin mm afor y Afinti on s) , SKIN, HAriFRioLOfi^ «n
(MttttHft ultntijiul with Ctnbuncle), Sui'i'URv-
no\ (Treatment, Ojwatitv) T\p]ioiD KFAER
((fttm/iliiation^f Cutaneous tiy^tein)
Carburetted Hydrogen.— M«u sh
tf.iN, mi'thtiiif, 01 methyl hydnde (CH4) is hu;ht
carbmc'ttcd h^dio^on, and has, in iarc inslaiiLCs,
been oxpcllixl fimn the iiumtli in flatulent djs-
popsia (vide IMHOKSTION, Ffnfulent Dyywjwa) ,
iiiethaiu 1111x1*1 ^ith «ui is the hie damp of co.il-
innms, and may cau^o explosion? Ethyleiie
or olcfunt j;as ((^llj) is heavy c.ubnrottcd
hydiogen
Carcinoma. $«- TUMOURS (Epithelial
frroup, Catcinoma) *SVf a/so CANCER (foi cioss-
ref<»renceb)
CarclnOSiS. — Cancer or the canceious
fochcxia , tho mftiwov* have been rej««iidod as
including tubeiculobi.s as ^ell as cancels
Cardamom! Sem I na.— Cardamom
seeds are got from the JShttaiia ra)damonium ,
they contain a volatile and a fixed oil, and h.ive
a pleasant tubte , and they are iibed ,is a ( ar-
mindtive and stomachic medicine The official
prepaiation is the Tinctiira Catdamomi Com-
CARBOLURIA 55
(dose, £ to 1 fl dr), but cardamom is
also contained in the Pulvis Cretre Aromaticus,
the Ti net ura llhei Compobita, etc
Garden's Amputation. Sec AMPU-
IAIIOXS (Catdai'i)
Cardia. — The heart, or, moie commonly,
the point \\heie tlie ousophag is opens into the
btom.uh tS'ee AM. IN A Pruoum, etc
* Cardiac. — Belonging to the heart 01 to
the a'sophageal opening into the stomach For
(.atdinc asthma, we ASTHMA , for rardtac contrac-
tion^ *•' HEARI, PrnsioLooy OF, and PHYSIOI OGY
(Circulation), for cardiac ctuc*, tee TABES DOR-
SAI is (tiyniptornato/oi/i/, Cranial Nerves), for
tnrdiac divnsei, v» HEARI, MYOCARDIUM A\TD
KNDOC inniL M , HEAR-I, NEUROSEM , HEARI, Co\-
dLMiAi MALI ORM 11 IONS foi cardiac jmin, see
ANGINA PFCIORIS, and foi cardiac t,ound<* (petal),
«<» PRFJINANCY, I)l \(»NOSls
Cardial£^ia. — (listric p.un, especially
pyiohis 01 hcaitburn >SV Ci^si-WALi^ AI-FFC
IIONS 01 (Patn in the Chevt), LNDIO&SIION
(tiymtitom*) , SIOMACH AND DUODENLM, Dih-
EASKS 01- (fjtntraf tiyinjttoiimtolvt/y, Eiucta-
i twin)
I CardiOCele. — Henna of the heart
through the thoiacic \\.\\\ or into the abdomen
i CardiOCentesiS. - Canhocentesis or
punctnie of the heait as a means of treatment
in <ascs ot asphyxia, chlorofoim-naicosis, etc,
ib not fioe from dangei, but its trial has been
to some extent \\aiianted by experimental
evidence
Card iOdynia.— Pain m 01 neai tlie
hcait , angina pectons (7 v )
Cardiogram.— \ tiacmg of the move-
ment oi the apex of the heai t, obtained by the
use of the cardiowajth, \iluch consists, in its
simplest ioim, of a icteivinj; and ot a lecordmg
tamboui tonnccted bv a tube tie PII\SIOLO«Y,
CiR(lTiMH»N (Cm illation through the Ilrait) ,
PUISE (Heart 3foi<tintnt<<)
Card iol ith. — A cal( .UCOUK conci ction
oecuning in the hcait, e (/ on one of the
Card ioly SiS. — Resection of the ribs in
cases of adhesion of the peruaidium and great
i \Cbsels 10 the steinum, lunns, diaphragm, and
struc tines in the antenoi and posteiior medias-
tinum, foi the pmpobc of lehcving the heart's
action (Jlraver)
Cardiomalacia.— Simple softening of
the heart, as in obsti uction of a small blanch
of a coionaiy >essel jSV«* HEART, MYOCARDIUM
AND P^NDorARDiUM (Jforlsid Prf*ce\ie* , A$ectiont
of the Myocardium), NEPHRITIS (Di/erent
Clinical Type* , Circulatory System in)
56
CARDIOMETER
Cardiometer. — An appaiatus (? </
Roy's) used to measure the output of the
heart m experimental woik See PmsioLO(,\,
CIRCULATION (Physiology of the limit)
Card lOptOSiS. — Displacement of tho
heart m a downwaid dim turn, occulting m
association with cnteroptosis or fioin accommo-
dation A voluntary form has been repoited in
\vhich a man had such command over Ins dia-
phragm that ho could dislocate his heai t,stomach,
and kidneys at will (Ah am*)
Card iorrhexis.— Ruptun> ot the heait
CardO. — The axis Aertebra, liteially a
hinge
"Carforal."— A water-filtci consisting of
iron, charcoal, and clay
Caries- — Ulcciation,gencially applied only
to that process as it aiiects a hone See CIUL-
DREV, Cl INirAL KXAMINAIION OK (Neck, ,SV///lf»<w) ,
JOINTS, DISEASES 01 (Definition of Term*),
JOINFS, DISF\SES OK (Tttbetculout Diwaie) ,
NOSE, ACCESSORY SIMSES, IMIAMMATION j
(Causes) , SPI\F, Suiiuiru Antcnoiss (S/nnal i
Cat tcs) , TEE m ( Den tal ( '(it ies) j
Caries SlCCa.— A chiomc form of tuber '
culous arthritis, occumng chiefly in the shouldei '
and hip joints of adults tire JOINTS, DISEASES
OK (Tufmrufar Diseases,
Car I nated.— Keeled 01 furnished with a
central gioove 01 iidge, tho abdomen may be
cannated in tubeiculous meningitis in children
•SVe MEMNC.HIS, TUIIKIUUKUS AND POSTERIOR
BASIC
Carlsbad. *Sf«- MINI- HAL WAIKHS (Thet-
mal, Alkaline)
CariTI i natives. — Medicines, sue h as
aromatic 01 bitter substancCh, stomachics gcnoi
ally, etheis, tumphois, and \olatile oils, which
increase the tf.istnc and intestinal mu^ciil.u
action, and so tend to expel flatus One of
their uses is to pievent the gnping caused b)
purgatives, and they are usefully combined
\vith anticids in CMSCH oi acidity (e «/ with
bicarbonate of sofla, etc) The Cm mi native
Tinitureot the Jhitish l>haimaco])a>iaConfeience
contains (uulamoms, strong tmctuie of ginger,
oil of cinnamon, oil of cai.iwav, oil of cloves,
and rectified spirit, its dose is 2 to 10 m
Carniferrin. — A picparation containing
meat and iron ,SVe CHLOROSIS (Treatment)
Carniferrol. — A propaiation containing
peptomsed meat and non
Cam ificat Ion.— The tiansformation of
a tissue or organ into a substance of flcsh-hkc
consistence and appearance, e (j the lungs in
atelectu»is and inflammation
Carnin. — One of the so-called punn bases ,
an end product of the breaking up of tho
nucleins of must le , its formula is C7HSN4(),
Carnlvora. #«• ANUHIAX
Carnochan's Operation. — The
antial method of reaching and i emovmg
Mcckel's ganglion in tngeminal neuialgia
See NKRNES, NEURAIGIA (7'>««/emm<i/, Nut weal
Ttctttment)
Carotid Artery. ^ AN EURYSM (Ne< (},
NERVES, NEURAIOIA (Tm/emtnnl, fayatuie of
Caiotid) , (KbiiniAdUs (Fo»en/n liwliei, Ulceia-
titm wtn Carotid^), ORHIT, DISEASES (Pitliaitiny
fi rophthahno*?)
Caroti n. &? CARKO i IN
Carpal Bones. <sw AVUIM -JOINT, l\-
lURtJbs (Fta< tine)
CarpholO^y. - Seeking 01 picking mo\c-
mviit*» ot the hands notued in dehnoiis patients,
"picking the bedclothes" It is denvcd horn
KU/H/JOS, c haff, and Acytn, 1 collect , and it is <i
serious symptom in the delnium of typhoul
fevei
Carpo-pedal Spasm. ,sw r\\\\\\
(Causation, Jtnlftt)
CarpUS. X™ Wrtih'i -Joivi, IMURIFS,
Wuisi-JniM, DISEASES
Carrageen. — lush moss, the thailus ot
Chomhui (litmus tfee INVMID FEMUNO (Cm-
ttiyeftt Jdly)
Carratraca. #« lULM-niixn (fyam
ami Pwtm/al)
Carreail. — Th<> name i;i\en by Fieiuh
v\iitcis to cases of tab's mcsc'iiteiica in which
there is haidness and enlaigement of the abdo
men , the name signifies a tile or buck floor
(tilf MbSfcMERIC (il AMto )
Carrion's Disease. ^ \E>UIU<.A
PKUUANA (lli^oty)
Carron Oil. — K<iual pait« of lime watei
and linseed oil AVc BURNS AND S^AIIIS (Treat-
ment), CALCIUM, etc
Carrot! n. — A colommg mattei obtained
fiom dijed and powdered (.irrots, it is said to
be used to give a colour to buttei , its formula
is regarded as C18H24O Hee PH.MENIS 01? HIE
BOD\ AND KXGREIA (Lijtochromet)
Carrots. Xee Pmsioixx.^, FOOD AND
DiGEhrioN (Vegetable Fuod-Stufia)
Cartilage. *SVe PHTSIOLOOY (Tiivues) ,
JOINTS, DISEASES (Ulcetation of Cattilaye) ,
CARTILAGE
57
KNEE-JOINT, INJURIES (Dislocation of Mmttunnt
Cavtilatje*) , etc — There «uc many cattilages
bearing special names, e y Meckel's caitilagc,
ensifoim cartilage, Santonin's caitilagc, etc
Carul FrUCtUS. Nee VH \RMACOUM A ,
PiucM'Riiiivn — C<u away fiuit, the aromatic
carpels of an umbel hfcious plant (Cnntm ca-nn)
There is an Ayun Carat, given in doses of 1 to
2 il oz The volatile oil, Oleum Carut, is the
chief coiihtituent, and it contains caivone
((J15H24), cymene, caivol, and limonene, it is
given "111 doses of J to 3 m On account oi then
pleasant, spicy taste and aiomatic odoui, caiaway
cai pels are used in making of powders, tmct'iies,
etc The oil is a carminative
Caruncle.— A. small fleshy outgiowth,
existing 1101 malty m the body (e '/ the uvula,
the prostatic lobe, and the lauyuial < arunde at
the inner canthus), oi developed as a pat ho
logical pi (xl act ion (eg the uiethial cai uncle,
nciuoma, or \ascular tumour giowmg neai tin
nieatus iiimanus in the female)
Carunculae Myrtiformes. — The
fleshy bodies which repusent the Imnen aftei
that mombiane has been toin in coitus and |
compiessed dining laboui «S'<? \UL\A, Dish *SES
o* (A foib id Condition* of the Hymen)
Cams. — Deep sleep, or, at coidmg to some,
coma or sopoi , <am* tnttifffiwi is simply
catalepsy, cam* Itlhatnu^ is piolongcd scmi-
unconsciousness or trance, and cam* ectfai,ii>
is ecstasy *SVt* CATUKPS* , ECSIASI , INS\NII\
Carvol or Carvone. -A eoustituont
((J1()1114O) of oil of t aiaway and oil of sprat mint ,
caivauol is an isomeiic- foim of it, and caivme
(C1(,lllb) is a teipone oi hmoneno .SVe (1\nui
.— The substance of the
nucleus as distinguished from that of the cell
(or cytoplasm), the endoplasm , the term has
been some\\ hat indefinite ly used fin eithc-i the
chiomatm or the adnomatin of the nucleus
CasamfCCiOla. Xee lUi NEOLOGY Jtaly,
CaryOCinesiS.— The changes m the
nucleus occulting during mitosis 01 indirect
cellulai duision tfte PIIYMOU)M, THE CI-LL
CaryOphylliim.— -The (hied flowei-buds
of Ew/cnia mryojt/tyllatii, oi doves, having a
pungent .md aiomatic t.iste anil a spicy odoui ,
they contain caiyophylhn, eugenm, and .111 oil
(0/eunt Cat yojthylh, oi oil of tlo\cs) which is
othci.il (dose, ^ to .'J m ) , of clo\es itseli theie
is an othcial picpaiation, the mtusion (Intutum |
Caryojtkylh), given in doses of } to 1 fl o/
Applied extemally, oil of do\es acts as an
irritant, and latei as a loi al an.esthetie ,
internally, it is a stomachic and caimmative,
and by its action on the stomach it icflexly
stimulates the heait and circulation, it is also
used m toothache fiom decayed teeth, as a
topical application To pi event gnping, oil of
cloves is used in compounding the Pihda
Colofi/nthidis Composita and the 23dula Colo-
cynthidiB et Hyowyami See THABMACOLOGY ,
PBESCUIBING , ami VOLAN^E On^
Cascara Sagrada. <S"
COUX.Y, PKKSCIIIJHNO , PUI«,AII\ES —The baik
of the Call foim, in buckthorn (Rhamitu^ pm-
tJuanw), h<i\mg A matkedly bittei tastc>, and
containing cascann, pmshi.unn, a volatile oil,
lesins, etc There ai e tin ee ottiual prepaiatiom*
the Ettiactiim CiwaiiP timjiadw (dose, 2 to 8
grs ), the £ihtntitm Caveat a1 tiaxfindw Lu/uiduui
(dosj, {, to 1 il cli ;, and the Nytujiuv Cav.ane
Ar»mni'n.ui (dose, i to 12 fl dr ) The liquid
PI ft art niaj be usefulh combined with Spintus
Ammonia.' Atomaticus, Spmtus Chloiotormi,
Tinctuia P>ell.idomuv, and Tinctuia Nucis
\ouuidu (equal paits of each), to foim the
2'inctwa Ltnattva (dose, 20 to bO m ) As an
apeiient, cascaia finds its gieat spheie of useful-
ness in the treatment ot chtonic constipation ,
it does not gnpe much, it can be used daily
without increasing the dose, and after the
constipation has been relieved the ding can be
giadually discontinued It may be given m
association with euon^min and nidm, with nux
\otmca and belladonna, and with non
Cascarillae Cortex.— The baik of
CmtonEluttna, containing the bittei substance
cascaiillin, \olatile oils, resm-s, etc It has two
othc lal piep nations, the Jnfuti/m Canardltv
(dose, \ to 1 H o/ ) and Tttutuia Cas<atill(p
(dose, f to 1 fl di ) , and it acts as a bitter and
btomac hu medu me Theie is an incompatibility
between the tmc tine and mmeial acids
Case at ion. N^ llitoisrm, JJuoNCifiAL
(Ji \M)S (M ot bid Anatomy) , TrnFRrui osis — V
foim of neciosis ot the tissues in which they
become con \eited into a dieese-1 ike substance ,
it is seen topically in tubeuukteis, and it may
follow eithet c«>agulatioii-nec losis oi a granular
diMiitegtation ot the tissues It is mote collect
to tetm cassation a post -nee i otic state than a
foim of neciosis (diem field and Li/on)
Casein. — A pioteid substance occulting
in milk (in the form of cascmogen, a nucleo-
ptoteid), and foinnng a gieat pait of cheese
,s'<v PinMomi.^, FOOD AND Dic.hsnov, MILK
(Pfiyi>i(ilo</i(.al) , JMALIU KKhniNo , etc Casein
bisc uits aio used in dial>etes mellitus
Pulpa.~The pulp fiom the
pcxls of the purging cassia (Castm fistula), con-
taining a puigatuc principle (cassm) It is
contained in the official Conjectw tiennw, and is
not given in any other w ay See PHARMACOLOGY,
PRESCRIBING, PURGAIIVEH
58
(\\STKLLAMARK
Cartel lamare. <SW THERAPEUTICS,
HEALTH KESOHTS (Italy]
Castellamarl di Stabia. *s>e
UALNEOIOGY (Italy, Hay of Nuple*)
Castor. — The dried picputial follicles
(with then senction) of the beavei (Castor
Fibci), it contains a icsinous matter, ca^tnnn
It is known officially as Mo^chin 01 Mink (i/ v )
«
Castor Oil. See CONSTIPATION , PHAR-
MACOLOGY , I'jtkM'RIlilNd , PUIUI \1I\ES , ct( —
Oleum, Ricuu, the oil expressed from the seeds
of Iticniu* lommunity consisting chiefly of
glyceryl in inole.ite, ^1jHft(ClsHSl(),)ll or ittni-
oletne, a fixed oil soluble 111 alcohol , ruuune,
which has been described as an alkaloid with a
iorniula of CJtH^N7O3, is doubtfully so, and
has no purgative properties, anothei constituent
is nctn, an albumose lesemblmg in its action
the abnn oi jcquinty seeds The dose of castoi
oil is 1 to 8 11 ch It has a nasty taste and
Hindi, only paitly concealed in the official
Mntu.ni Olet Hicmi (dose, 1 to 12 11 o/ )
Indeed, no plan of getting o\ ei the diflu ulty ot
the taste succeeds so well as the holding of the
nose till the ding has been washed o\ei the
fauces by such a liquid as coffee , for if the
nose be held only dm ing the swallowing oi the
oil the smell is apt to pass up the postetior
nares and cause nausea <1astoi oil is a veiy
valuable simple purgative, and is specially use-
ful in children, in piegnant and puerpciai
women, and m adults and old people of both
sexes who may bo suffering fiorri h<emoii holds
It may be given, with olive oil, as an enema
Externally, it is used sometimes as a sedative in
cases of conjunctivitis (*•// due to the mtio-
duction of an niitaiit into the eve), \\hen it
can be diopped into the eye, eithci alone oi in
combination with cocaine
Castration. tie ORESUY (,sw), PROS-
TATE (JlANl), Ihl'EUIHOrm (TrnilHient, fttillCdl),
SCROTUM AND TAMK i », DIM. ASKS or (Ejmvon ot
the Testicle)
Catalepsy
Casts.
llnnMiii, RROxruiTis (Mot ltd
Cata». — In compound woids "cata-" (01
"kata-") has gcneially the sense of "down,"
"downward," "descending," "declining", but
sometimes it means " pel verted" or "thoiough "
It is contained m many words (as well as in
those special! v. named belo\\), such as ( atacasmu*
(deep scanhcation), tataiautis (deep burning, 01,
perhaps, " spontaneous combustion "), catachysn
(a douche), cataclysm fa dyster), cntadioptric
(reflecting and lefractmg), cataplasm (a plaster),
cataptons (an apoplectic oi epileptic fit), etc
CatabollSm. — Catabohsm (or kata-
bobstn) means the descending, disiuptive, or
disintegrating changes which may take place in
metabolism, in contiadistmction to the ascend-
ing, synthetic, or constitutive senes of changes
which constitute anabolism
Catabyth ism US.— Suicide by dioun-
mg Catabythivnomama is the foim of suicidal
m, ini.i \\huli seeks to accomplish its end by
(Iron nmg
Catalase. — An enzyme or /ymin found
in many tissues, and capable of bi caking up
hydiogen pei oxide
talepsy. *<? a/so HYPNOTISM,
KIA, HYSIMUA IN CHILDHOOD , INSANITY,
NAUUHE AM> SIMI-IOVIS (Cnhilej'tit A'<w/>o>),
SPASM (I/yvtetHal)
Eiiouxii »">8
S\M1"IOMS 58
TllEA'lMJiM r)0
PlMK.NOSIS •"")&
NAllltJi AM> I'VIIKIIXN.^ ")0
D]tHNiiu>\ — (1atalepsy is a ncivous affection
chaiacteiised by a plastic ugidity of voluntaiy
musdes , by unconsciousness, uu hiding the
abeyance of common and special sensibility »
and by the abeyance ol rellex 111 liability
KiioLtXii — Females aie dispi opoi tion.itely
j)i edisposed to catalepsy, and the pcnod oi
adolescence is a common ajre for its occunence
The affection is piedisposed to by any ( onditions
which make ior ncui asthenia, it has obvious
katamcnial iclations in m.iny cases , <uul, both
in males and females, theie aie usuallv some
suggestions of hystona ^ely commonly the
fust attack is occasioned by some mental or
neivous incident of a violent natuie — a fire, an
assault, gieat religious excitement, a fall, a sun-
stiokc, a sudden affliction, and similar emotional
OT neivous shocks Cataleptiform affections
may appeal in association with that form of
insanity (ailed stupor, with hystena, vuth
tetanus, \vith choica, and with epilepsy, so as
to suggest an etiological relationship
Si if nous - The first attack of catalepsy may
be quite unexpected But the affection is apt
to be paroxysmal and even periodic Kven m
such cases the patient may be quite well be-
tween times, but it is veiy commonly the case
that a more or less sudden giddiness, or head-
ache, neuralgia, hiccough, or visual disorders
immediately precede a sei/ure Therein wo
observe a first resemblance to epilepsy, and, to
appreciate the condition, we must constantly
keep that comparison in mind
Whethei thcie has been warning of some
minutes or longer, or if there has been none,
CATALEPSY
59
the patient IH, at the instant, usually aware that
she IB about to fdll With peihaps some vague
efforts to kneel or to reach a seat, she sinks
helplessly to the floor 01 subsides in her ch.ur
Apparently, in a typical sei/ure, the conscious-
ness of the patient is as it may be in a deep
swoon The List fact that she is aware of is
that she has lost contiol of her muscles, and she
appears to know no more until she recovers
some minutes or hours or e\en dajs latei She
has then no iccollection of vvh.it has tianspned
meantime Whether 01 not theie be an) iso-
lated mental activity during a sci/urc, \ve have
no means of knowing
Meanwhile motor symptoms of a most m-
tei esting c li.ii acter have been dev eloped Thei c
is no violent tonic spasm in catalepsy Hut
there is fixation of the muscles of a nature
which is curious and not easy ot explanation
An epileptic will ciash to the ground .is a mle,
and then, of course, clouu spasms follow A
hysteiical patient mill fall with some slight
arrangement of bet limbs and sknts, and othei
signs of apparent puipose in her movements 01
in her pose Hut in a typical cataleptic sei/uie
the patient (hops off as in svneope, and her
muscles become fixed in the fust attitude at
which she comes to lest ff jou try to hit a
limb, or rear range the body generally, jou mill
find that the muscles ha\e stiffened .is if in ngor
mentis Then by degrees they gently relax, so
as to adapt the- pose to the a< tion of gravitation,
and the trunk and head and limbs all sink
flatter on the ground 01 couch At this stage
the muscles have reached the chaiacteiistic con-
dition of plastic, ngidity, the distmctixe featiue
of catalepsy known as Flecibilita* trtm The
figure is not now cast in metal but in max, and
is plastic uiiclci youi fingers It letams any
pose which you make it assume Theie is no
automatic movement of a purposive* kind, no
lifting of an aim en hand 01 loot, and then* .11 e
no spasms If you i.use a limb to a position of
stiani, the muse les will ictain that pose tin a
time, and then by slow degiees mill allom the
limb to sink to a position deter mined b\ gravity
At this stage the sensibility of the patient
mill be abolished The skin is appaiently quite
insensitive to touch, to heat, to pain, to elec-
tricity Special sensibility is abolished Reflex
irritability IK also in abeyance Even the con-
junctival reflex- is piobably abolished Jlespiia-
tion is veiy shallom , cardiac action is slight ,
and the tempciature slomly falls
A typical sei/uic has been described Very
commonly theie will be important modifications
in the symptoms Jn paiticulai the conscious-
ness and the sensibility of the patient may not
be abolished, though pomcilcssncss and plastu
rigidity may have supei vcncd The reflexes
may not be gieatly impaired, though common
and special sensibility is in abeyance Ilypei-
sensibihty has been repoited as a rare vaiiation
As in other such dise.iscH, there are cases of
spuiioim catalepsy, in some of mhich symptomn
of h}steru aie conspicuous, and cataleptoid
elements «ue frequently prominent in allied
aflections
TiiBA'iMKNT — Dwtntf an attack treat the
patient as foi an epileptic sc-i/ure Put the
body in a position of ease, and do not distuib
the patient In the majority of cases spon-
taneous awakening occurs at the most aftei a
ten houis It is difficult to see mhat good is
si'ived by violent attempts to arouse patients
fiom com i (ilentli means mav occasional!} be
tiled — a sharp pnftof mind on the face, a bieath
of smelling salts, a pinch of snuft, or even a veiy
mild splashing of <old mater Avoid emetics
and painful shocks ot cleetncity It the attack
continues, food miy be necessaiy If so, pass
it into the stomach by the tube, 01, in the hist
instance, empty the icctiim and adnnnistei a
null lent enema Dram oil the urine it there
«irc reasons foi supposing th.it theie is any con-
siderable accumulation It the patient is coin-
foitablv in bed and these measures aie adopted,
theie is no leason foi supposing that the
citaleptic sleep mill be hurtful, even if it is
protiacted ovei seveial da}s
Aftn an attatl, tieat the patient as for
neurasthenia A\oid icgarding the case as
hxsteiual (\>nsidei it lathci as cpileptoid
Ti> to disco\er any mental 01 physical source
of nutation, and remedy it it possible As m
chorea, the patient may be gieatly benefited by
a change1 of scene, especially it that entails a
removal horn the chief source of annoyance or
excitement Special ugaid should be had to
pehic fattens in the disease
I'KOC.NOSIS — The prognosis in each sei/mc is
good, .ind the piospect of immunity fiom attacks
is also good, and increasingly so according to
the age ot the patient
Difftientml /J/r/r/Mosis - In vtujwi there is
more 01 less persistent mental disordei In
hytfaia the plastic itv of the limb receives some
added effort of its own A cataleptic limb is
moved from one position to anothei, and mill
retain the position in mine h it is placed for some
time A hysterical limb generally moxes By
judicious eh inge of piessuie or ot diiection you
rnaj observe the hysterical limb continue to
move without youi aid, or continue to oppose
a stiain mine h you ha\e vuthdramn In tetanus
there is spasm, and generally obvious signs of
pain In ejn/c/*y there are fust spasrns, and in
the later stages the plastic rigidity is absent.
In the cataleptic state induced by hyjmoti sm, the
symptoms, in this country, vary considerably,
and in geneial there is, as in h}steiia, a feeling
on manipulating the limbs as if the patient weic
following your movements In death physical
signs discoveiable by auscultation are wanting,
and the ny<n mot tis is not plastic
XA i UIIE AM) PATHOLOGY —We have no definite*
60
CATALEPSY
knowledge of the pathology of catalepsy The
nervous condition previous to a seizure must be
held to explain, m a histologist's sense, the
nature of the lesion, and it probably is coinpai-
able to other related diseases — mania, hysteria,
epiloptoid states, etc As to the seizure itself,
and its effects, it is important to consider \t hat
are the mechanisms which are chiefly imolved
It IB obvious that the lesion is partly cortical,
and that it involves mechanisms which subserve
perception and volition The coma beems to
have features which distinguish it from that of
sleep, of induced hypnosis, of epilepsy, or of
swoon The mode of invasion is charactenstic,
and the muscular accompaniments, and the
depth of insensibility Apparently the lesion is
one which specially involves the outward lealm
of mental mechanisms — those which subserve
muscular activities The loss of voluntary move-
ment is the prelude to the curious phenomenon
which persists — the plastic rigidity in voluntary
muscles The invasion of consciousness would
seem to be somewhat similar to what occurs in
certain epilcptifonn attacks (not epileptic) in
which the spasms of voluntary muscles initiate
an attack in which consciousness is thereafter
lost. In catalepsy there is paialysis of volun-
tary movement, followed by paralysis of con-
sciousness The most mteiesting phenomenon,
however, still remains — the balanced and co-
ordinate muscular contractions which determine
rigidity of the limbs, and their persistent
sensibility to pressures which dotei mines their
plasticity That phenomenon undoubtedly sug-
gests, as Cowers has pointed out, an affection of
the muscle -sense oigans Affeient fibics from
the muscles, fascias, and joints, and correspond-
ing motor tracts, complete a reflex arc whose
apex is in the spinal cord These mechanisms
subserve the function of unconscious balance
and pose In normal life, however, that reflex
arc has an extension up u aids to the cortex,
which makes possible a voluntary control of its
activities. In catalepsy the higher activity IH
in abeyance, and the lower mechanisms are
active in excess The rigidity then n simply a
secondary, positive sign of the removal of con-
scious control, and the plasticity of it is part of
its normal function — to adapt pose to stress
But the extraordinary thing is that this function
should persist when others have been abolished
— an isolated and excessive activity in a general
condition of profound coma We are therefore
led to conjecture that theie is something very
like an opileptiform seizuic in catalepsy, and
that the motor convulsion, if there is one, is a
convulsion in this mechanism to which we have
referred The absence of obvious spasms, either
tonic or dome, signifies only that the convul-
sion is not in a mechanism of largo movements,
which we already know The mechanism referred
to is a fine-adjustment mechanism. Its move-
ments are all small It would be instructive to
know if there are any oases in which, with pro-
longed unconsciousness, there are recurrences of
the characteristic muscular phenomena. Some
of the protracted cases may signify the passing
from one fit to another In any case, as all
authorities are agreed, the affection is in some
sense epiloptoid
Catalysis. — The effect produced upon a
body 01 substance by the presence or contact of
anothci substance, the latter being termed the
catalyser and showing in itself no change , it is
in this way that enzymes are believed to act (e g
in fermentation) , it has been supposed that the
catalyscr does not really initiate a reaction, but
merely hastens it
Catamenla. See MENSTRUATION AND ITS
DISORDERS (Terminology)
Catapasm.— A dusting-powder
Cataphasla. — A disordered state of
speech, a \vord or phrase is lepeated or afhrmed
(Karctya<m, affirmation) ovci and over again,
either as an answer to a scries of questions or
apart from conversation
CataphoreSiS.— That action in which
galvanism aids a substance 01 solution to pene-
trate the tissues acted upon , a sort of electric
osmosis. See Trail! (Electio-Catap/unest*),
Cataplasm.— A poultice , occasionally,
a plaster See PRESCRIBING
Cataplexy.— Mesmeric sleep mammals,
shamming death, or a temporary paralysis
CataptOSlS.— The sudden feeling of a
patient affected with epilepsy or apoplexy
Cataract. See alvo DIABETES MELLITUH
(Complications, Affections of the Eye) , EYEBALL,
INJURIES OP , GLAUCOMA (Causes, Cataract-
Ojmatwns) , OcuLAii MUSCLES, AM ACTIONS ot
(Nystagmm)
INTRODUCTORY
FORMATION OF
TRAUMATIC
IDIOPAIHIC
DIAGNOSIS
CONGENITAL
TREATMENT
OPERATIONS —
1 Reel motion
2 Ductssum
3 Ettrdction
AFTER-TREATMENT
60
61
61
61
62
63
64
65
65
66
68
TECHNICALLY, the name cataract is applied to any
iutransparency of the crystalline lens Popularly,
only those lenticular intransparencies which by
their distribution and their density cause more
or less considerable impairment of visual acuity
are looked upon as cataracts It is also
CATARACT
61
common to talk of cataract developing when
the mtransparencies in the lens are of the nature
of progressive degenerative changes
From a diagnostic point of view it is often
important to distinguish between the "sta-
tionary" varieties of cataract in the technical
sense and the "progressive" foims The
former arc also called "paitiul" cataracts,
whilbt the latter eventually become " total," or
practically total, cataracts
FORMATION OF CATARACT — The loss of trans-
parency which causes a progressive cataiact is
invariably the result of some degenerative
change The extent, moreover, to which these
degenerative changes go leads to difleient
appearances There thus come to be distin-
guished a number of different varieties of total
cataract Only comparatively few of these
varieties have any piaclical importance The
importance which may attach to them prac-
tically has reference to the selection of the
most suitable operation for their removal, and
consequently also to some extent to the prognosis
of the result of operative interference
A number of tenns aie m use to designate
the stage at which a progressive cataiact has
arrived Thus iti any particular case the
cataract may be "incipient," "advanced,"
" ripe, ' or " ovei-ripe " The meaning of the
first two tenns is self-evident A cataract is
ripe when the whole of the lens has lost its
normal transparency As a rule the sclciosed
central portion of the lens, which is met with
after the age of about thirty, and which foims
as ago advances a greater and greater piopoi-
tion of the whole lens, the so-called " nucleus "
of the lens, does not at first paiticipatc in the
loss of transparency It is therefoie the totality
of the sui rounding and more supeifieial or
"cortical" poition of the lens which is the site
of a degeneration causing the transpareiu y to
be lost
When the whole " cortex " has become m-
transparent, then the cataract is said to be
ripe The term "ripe" lias refeience to the
circumstance that the lens proper is then
readily removed out of its capsule like a ripe
nut from its shell.
The further progiession of the degenerative
changes which ha\e caused the total mtrans-
parency lead to over-ripe cataract Thus the
cortex may become liquefied or cretaceous In
addition, the lens capsule may in part (over an
area corresponding to that left uncovered by a
semi -dilated pupil) patticipate in the loss of
transparency or the suspensory ligament of the
lens undergo degenerative changes These
latter changes are of importance from the point
of view of treatment
When once the lens cortex has lost its
transparency, it is extremely rare that the
transparency is regained Practically speaking,
there is therefore no cure for cataract in the
sense that the eye can recover its normal
condition Absorption of the altered lens sub-
stance may, however, take place spontaneously
In many cases this can be induced by surgical
interference When the intransparent lens is
thus got rid of by absorption, the obstacle to
the formation of retinal images is lemoved and
sight is restated The optical condition of the
eye is, however, different from what it was with
the transparent lines in situ Generally the
ne\v condition is one which admits of less sharp
ictinal images Sharp \ision can then generally
only be got by means of a glass The object of
most cataract operations is to get nd of the
intransparent lens In all cases of total cataiact
this is necessary.
Cataract may be either tiaumatic or idio-
patlnc However arising, it is essentially due
to some defect in the nutrition of the lens
hbies
TRAUMATIC CATARACT is either the direct
iCNult of some mtciruption in the integrity of
the lens capsule, or the imlirft t result of injury
to other parts of the eye In the hist case the
loss of transparency of the eiy stall me lens i»
due to its coming into direct contact with the
aqueous humour In the second case the injury
to deeper parts of the eye leads to intraocular
changes, with which are associated changes in
the character or in the amount of the nutrient
liquids which peicolatc the lens
In order that the lens may remain trans-
parent, it w nccebsaiy that the lens capsule
should bo normal. The smallest breach m
continuity of this membrane leads to intrans-
paroncy.
A cataract caused by a wound of the capcule
makes its first appearance veiy soon, in a few
houis at most, after the mjuiy, and afterwards
develops more or 'ess lapidly according to
circumstances Very rarely, and only m cases
in which the laceration of the capsule is very
minute and has rapidly cicatiised, the mtraus-
parency of the lens which follows may remain,
paitial, or e\cn slowly disappear altogether.
This rare result is only met with too in young
children
The laceration of the lens capsule is usually
caused by a perforating wound of the eye
Occasionally a shaip blow on the eye may
cause a inptuie of the capsule, and the result
is similar, % 12 an immediate loss of transparency
of the lens.
Such cases of capsulai injury, either by per-
foration or rupture, cause, then, what may be
called a direct traumatic cataract In other
injuries to the eye unassociated with injury to
the capsule, the cataract which may follow is
"induect" An indiicct traumatic cataract
only makes its appearance weeks or months
after the injury
IDIOPATUIC CATARACT again may be either
" primary " and uncomplicated, or " secondary "
62
CATARACT
to some other disease which of itself has caused,
or is likely to cause, serious interference with
vision
Of the primary cases, uncomplicated so far
as any other defect of the eye is concerned, two
groups may be recognised The firs'" group,
fortunately by far the larger, includes all the
cases m which there is no evidence of <my
general condition of malnutrition In the >
second group there may bo more or less reason,
on the other hand, to connect the loss of tians-
parenoy in the lens with some such condition as
albummuria, diabetes, etc
Idiopathic cataract, when primaiy and occui-
nng in an otherwise healthy individual, is most
common after the age of sixty On this account
it is usually known as senile catatact There is,
however, no necessary connection between this
variety of cataract and other evidences of
senility In many cases thcie beems to be <i
more or less evident hereditary tendency to
cataract On the whole, it would appear, too,
as if the younger the individual affected with
cataract, the more evident was the hereditary
predisposition.
Apart from heredity, which is by no means
always traceable, there does not appear to be
any general state associated at all intimately
with the appearance of ratal act All that can
be said is that, on the whole, there is a tendency
increasing with age for the nutrition of the lens
to become impaired, and that this tendency is
greater in some families than in others Prob-
ably the s tincture of the lens itself predisposes
to defective nutrition The lens is an epithelial
structure, which, as time goes on, becomes moie
and more compressed and sclerosed in its ccutial
portion This compression results from the
continual growth of new lens fibres which go to
form the outer layers, whilst the old, effete
tissue, not being removed, gradually accumu-
lates The oldest and most horny portions of
the lens, instead of being rubbed off, as in the
skin, aie thus collected in its centre This
arrangement of itself seems to predispose to
difficulties of nutrition These difficulties are
more insuperable in some individuals than in
others, altogether independent of anything but
mere local conditions Whatever be the true
and complete explanation, it is of piactical im-
portance to recognise that the term senile as
applied to cataract has only a icstricted sense
The appearance of cataract is therefore not
necessarily, or even commonly, an indication of
any general breakdown
Most cases of ben lie cataract are cortical
cataracts, te the loss of transparency which
takes place is limited to the cortex In
and then usually assumes a dark brown or
almost black coloni This is sometimes, and
especially when the colour is very dark, called
black cataract (cataracta mgra). A better
term is nuclear senile cataract. Although m the
aged the nucleus of the lens comprises almost
the whole of that structure, so that very little
cortex remains, the true nuclear senile cataract
not being such an essentially degenerative
change, a nuclear cataract does not cause such
a complete loss of vision as is caused by an
ordinary ripe senile cataract
DIAGNOSIS — Mere inspection of the eye reveals
a greyibh opacity in the pupil The pupil itself
is freely movable, contacting as light falls into
the eye, and dilating when the eye is shaded from
the light The history, too, is one of gradually
increasing blindness until the details of objects
have become indiscernible, and only the move-
ment of large bright objects in front of the eye,
01 it may be only the difference between light
and darkness, can be made out
The earlier stages of cataract, as well as the
differential diagnosis between visual defects due
to lutransparencics of the lens or to other causes,
can only be made with the ophthalmobcopc Any
in transparency m the dioptric media (the vitre-
ous, lens, aqueous, and cornea) appeals in the
dibc of juwJus tfjler (see "Kye, Examination
of") as a daik aica interrupting its continuity
When daik spots are seen in this way, the dia-
gnosis of the site of the intransparcncy has next
to bo made A preliminary examination of the
cornea and aqueous made by oblique illumination
enables us to see how far any intranspareiicics
m these parts contiibuto towaids the appear-
ances been with the ophthalmoscope If there
are no coineal nebula) and the aqueous is clear,
these parts of the eye can be excluded, and the
question then is whether the dark aicas inter-
rupting the fundus reflex are due to mtrans-
parencies in the lens 01 vitreous humour Opa-
cities in the viticous arc often movable, i e move
independently of the eye when once set in motion
by eye movements Lens opacities are, 011 the
other hand, stationary The differential dia-
gnosis is usually easily made, although m some
cases of opacities lying far forwards in the vitre-
ous there may be some difficulty
The pupil in old people often appears grey or
greenish grey It presents then a very different
appeal ance fiom the dark, black pupil seen in
earlier life. This grey appearance is duo to
light reflected trom the anterior surface of the
lens In young people the superficial layers of
the lens have a lefractive index very nearly
equal to that of the aqueous Consequently
little or no light is reflected from the suiface of
separation between these two media The greater
hardness of the older lens, with its consequent
greater refractive index, causes considerable re-
flection from the lens surface This reflection
is sometimes so great as to give the appearance
on mere inspection of cataract. Inasmuch, too,
as old people often complain of failing sight
from other causes than cataract, it is important
not to mistake the condition described for
CATARACT
63
cataract. All that is necessary to make the
differential diagnosis is the dioptric test with
the ophthalmoscopic mirror When no cataract
exists, the fund us reflex, so far as the lens goes,
is seen undisturbed throughout
Senile cataract is mostly met with m both eyes
Often the condition first begins m the one eye
alone The first appearances aie only seen with
the ophthalmoscope and \vith the pupil dilated
They are generally those of radiating peripheral
mtransparencies, the so-called stone The stage
of peripheral stiuc may last for many yoais
\\ ithout appreciably advancing Generally, how-
ever, the strite become continually moienuuiei ous,
laiger, and confluent Only small chinks of clear
cortex then remain Often this gives rise to a
multiplication of the images of objects seen — w hat
is called yolyoput Sometimes, however, the vision
icmams amazingly good, though the changes
aie often accompanied by alterations in the
optical condition of the eye Weaker reading
glasses are then often used, and the distant
vision is improved, it may be by concave glasses,
or if previously convex ones ha\e been required,
they may no longer be necessary
The furthci confluence of the separate areas
of mtiauspaitiiicy leads to the w hole of the coitex
being involved, and then gcneially pi city soon
to the cataiact becoming iipe The petiod
occupied m rtjitntw/, however, varies very much
As a lule, from the time the stiuu hist become
evident till the \vhole cortex is mtianspatcnt,
there IH an interval of time of from two to thiee
years But thcie are frequent exceptions to this,
and mostly in thcdircction of a prolongation of the
period of development It is therefore not safe
in any given case to veiituic upon too definite a
prognosis as to the date when the cataract will
bo ripe
There is often a very serious degi ce of blindness
long before the cataiact is ripe The bearing of
this fact upon the question of ticatmcnt is after-
wards considered
The stage at which opciation tor cataract is
most satisfactory is the stage of upcness Inter-
ference is on the whole less satisfactory bcfote
this stage has been arrived at, and still less
satisfactory when there is any maiked degree of
over-ripeness
The niovt important point whuh Aas to be in-
quired into tn the rase of a upe cataract is as to
whether or not the cataiact is uncomplicated A
ripe cataract, whilst it leads to the loss of any
sense of foim, so that surrounding objects are
not seen, does not materially interfere with the
sense of light Consequently an individual with
a ripe cortical cataiact has a good appieciation
of differences in degree of illumination The
light from an ordinal y candle flame in a dark
room can be seen, and the difference at once
recognised when, it is shaded by the obseiver
holding his hand in front of it, so as to prevent
its rays falling on the patient's eye, or the
difference caused m illumination by reflecting
into the patient's eye the light of a gas jet turned
down to almost its lowest point and then remov-
ing the reflection is at once appreciated One
circumstance, then, which would cause one to
infer that the eye was otherwise healthy, not-
withstanding the existence of a ripe cataract,
would be the possession of a, keen perception of
light On the other hand, a defective light sense
must cause suspicion of deepei disease. When
fltic light sense is veiy defective there can be no
doubt of the existence of complication And
this is, of course, still more the case when the
patient is unable at all to distinguish light from
darkness This condition is a complete contra-
indication to ojicration, as no sight could then
be 7 -stored by icmoMng the cataract.
Another point which has to be tested is in
the cataractous e)e called the projection Al-
though unable to distinguish ordmaiy objects,
an individual with npe cataiact, if the eye be
otheiwise healthy, should nevertheless have a
fair idea of the duection from which a bright
light comes Thus the direction of a candle
flame in a dark room, held close to him above or
below 01 to either side of the face, can be made
out. Although the mtransparcnt lens is not
capable of forming sharp images, it is able, even
in cases of npe cataract, to so far collect the
rays, whilst scattcimg most, that a maximum
illumination of the retina takes places in and
around the place at \vhich, uudei normal con-
ditions, the image of the flame would be formed
CuMiKMiAL CATARACT — In addition to the
forms of cataract alieady enumeiatcd, there is a
whole senesot juvenile and congenital cataracts
These may bo complete or partial, coitical or
nuclear
It is most important to letognise and to treat
congenital cataracts as caily as possible if they
aie cither complete or so extensive and dense as
to cause a serious impediment to vision If they
aie not removed within the first few months after
birth, the resulting vision is rarely good Cata-
iact developing in eyes which have once acquired
good sight may remain for an indefinite period
without mteifermg with the possibility of sight
being restored on its removal The immediate
result of a successful operation in such cases is
in fact the complete restoiution of the sight,
even if the cataract may have been there for
foity years or more There is no amblyopia
fiom disuse It is otherwise, however, where
the eaily development through practice, which
is necessary for the pei fee ting of the eye as a
seeing instiument, has been rendered impossible
Later operation will admit of a certain degree
of sight being acquired But the acquiring of
sight under these conditions is a slow, laborious
process, requiring often much training It
always stops short of perfection — often much
short of it Operations in the early months of
life give the best chance The necessity for
64
CATARACT
early operation is the main practical point to
keep in view in connection with such cataracts
Their diagnosis presents no difficulties, and the
differences met with in different canes are only
of scientific interest They are almost invari-
ably bilateral.
A complete cataiact exiting in one eye only
of a child is almost certainly of tiaunmtic origin
A careful examination of the coined will usually
m these cases reveal a scar, often a very iaint
one, owing to the rapid tissue changes of child-
hood. The scar indicates where the perforation
of the eye took place Curiously enough,
patents and others who bring young childien
with traumatic cataract long aftei the accident
which caused it often deny that any accident
lias taken place They usually admit it, how-
ever, when it is pointed out to them that the
scar is visible Sometimes, as, for instance, when
the penetration has been made with the point
of a fine needle or a fine pair of SCINSOIS, the
parents may actually be ignorant at the time
that so serious an accident has occurred
One of the most frequent forms of juvenile
cataract is what is called lamella r cata / act This
is a partial, stationary cataract It is either
congenital or developed very early in hie In
lamellai cataract only some of the leiib fibres,
which are arranged in lanielhe, are mtrans-
parent , hence the name The defect of vision
which this variety produces varies in degree
according to the position and numbei of the
mtransparent latnellte The pupil shows only
a moderate degree of opacity, sometimes, indeed,
so slight that it is difficult to diagnose the con-
dition without the ophthalmobcope The oph-
thalmoscopic appearance is chaiacteiistic If
the pupil be dilated it is found that a disc-shaped
darkening of the fundus reflex occupies a cen-
tral area of it The shaded area vanes in extent,
appears daikor at its margins, and is surrounded
by a clear zone Often the circular lino corre-
sponding to the margin of the opacity is broken
by little protrusions, which on closer inspection
arc found to be caused by more peripheral in-
transpurencies, which, as they embrace the edge
of the mam opacity, have received the name of
"riders"
Lamellar cataract is raicly noticed before
schooling has begun Then it is found that the
child's sight is less acute than normal Objects
m order to be seen are held closer to the eyes
than under normal conditions This attracts
attention, and is usually supposed to indicate
the existence of myopia Often, indeed, and no
doubt as the result of this too close application
of the eyes, the condition actually does become
complicated with myopia Anything, in fact,
which cauHos the persistent use of the eyes m
early life for the seeing of objects which lie too
near to them IH apt to give rise to myopia.
The question which has to be determined in
all cases of lamellar cataract is whether or not
it is desirable to operate As the operation
consists of removing the lens m some manner
or other, any power of accommodation mubt
necessarily be lost after operation. The question
to be considered then is whether the improve-
ment in vision which the operation will cause is
sufficient to counterbalance the risk of opera-
tion, the necessity for wearing cataract glasses,
and the loss of accommodation Obviously,
there must be some limit for which the advan-
tages and disadvantages are pretty equally
balanced This limit will vary, too, according
to the individual views of diiierent operators.
Some even go the length of operating on one
eye only, leaving the other untouched, so as to
letain as fai us possible both advantages, that
of increased visual acuity in the operated eye,
and retention of accomtmxlation m the one
which remains unopeiatcd upon This, of
course, is done at the expense of binocular
vision It is rare that such a practice is to be
recommended. Indeed, it should only be re-
sorted to when one eye is considerably worse
than the other, and at the same time the
occupation of the individual makes it seem
advantageous. In this respect each case must
be judged on its ments
A good practical rule to be guided by is to
recommend opoiation when the visual acuity is
less than ]jg, and to ad vibe the patient to have
nothing done where the acuity is greater than
this limit Here, again, however, one must to
some extent bo guided by the \ushes of the
patient, when matters have been properly ex-
plained to him or his parents, as well as by
the nature of the occupation which he follows
or wishes to follow
Lamellar cataract is almost in variably bilateral.
It bcctus to stand m some relation to rickets,
though in most cases the manifestations of
rickets aio not particularly pronounced Often
there is an absence of enamel on the teeth,
especially the canines Children with congenital
cataract m any form are occasionally of more or
less markedly weak intellectual development
Treatment of Cataiact — Nothing is known to
have any dchiute effect in checking the progress
of cataract The degenerative process seems as
a rule to be so intimately associated with diffi-
culties of nutiition depending upon the natural
structure of the ciystallme lens, and so rarely
dependent upon general conditions oi health,
that it is unlikely that the progression of
cat.ii act could be influenced by general treat-
ment It is conceivable, no doubt, that the
conditions of nutrition might be modified to
advantage by local treatment Hitherto, how-
ever, any treatment which has been adopted to
dissipate cataract has been by secret remedies
The favourable results claimed for such remedies
have never been substantiated. It is even
doubtful if any ordinary use of the eyes m any
way influences the process This being the
CATARACT
65
case, it is hardly fair to impose upon one'b
patients, as Boon as the beginning of cataract is
diagnosed, all sorts of restrictions instead of
allowing them to have the full use of their eyes
as long as possible Excessive, continuous
reading, especially with a bad illumination, may
perhaps he undesirable
When cataract has advanced sufficiently to
cause some marked interference with mght it is
sometimes possible to get some temporary im-
provement by the me of a weak mydtiatic or
miotic or by suitable y fosses In many cases of
advancing cataract it is found that patients
complain of seeing very badly when facing the
light, or generally, when the ilhnnmatmn IH
btrong In reading, for instance, they piefei
sometimew an illumination which ih otherwise
unsuitable owing to its being too feeble The
reason for this is that when the pupil is small
the total area of the portions of the lens w Inch
remain cloai is insufficient to give a bright
enough retinal image With a semi-dilated pupil,
howevei, the number of rays going to iorm the
image is gi eater And if the more exccntiic
pupillary poitions of the lens are relatively free
from intransparonucs, the proportion of effective
rays may mciease at a greater ratio than the
diminution in illumination, which causes the
pupil to become less conti acted A still greater
advantage may iindei these conditions be got
by causing an attihcial dilatation of the pupil
The greater number of rays thus admitted to
iorm the retinal image is not countei acted by
the diminished illumination necessary to admit
of a natural dilatation of the pupil This
aitificial dilatation of the pupil is best seemed
by the use of a weak solution of sulphate of
atropine (J gr to 5j ), which may be applied
daily, or even once every second day In
advancing cataract this should always be tried
If it proves ot use it may then be safely in-
definitely continued It is compai atively seldom,
on the other hand, that a iniotic by causing an
artificial conti action of the pupil is of use in
cataract
Patients with cataiact often suffer too from a
disagreeable degree of daushng This is caused
by the scattering of many of the rays which
enter the pupil These scattered rays, mixing
with the regularly lefracted ones, disturb the
clearness of the letmal images, and produce
this disagreeable sensation It is tor this reason
that cataract patients rarely face the light, or,
when they do, walk with their heads bent for-
wards They frequently, too, shield the eyes by
holding then hands at the side of the face, or
by shading the eyes in some other way Some-
times spectacles in the form of stcnopaic slits
cause improvement in vision by diminishing the
amount of this scattering
When the cataract m one eye is further
advanced than in the other, the same scattering
of rays in the worse eye causes the vision with
voi, ir
both eyes to be less perfect, and associated with
more discomfort than when the better eye IH
used alone It is then advisable to allow them
to icad with an obscure screen in front of the
worse eye
Another expedient which may be resorted to
when the Might is insufficient to permit of read-
ing with the proper correction at an ordinary
distance is to give up any attempt at binocular
reading and use the better eye alone It is
then provided with a glass of sufficient strength
to focus it for a distance of 6 or 4 or c\ en 2
niches instead of for 10 to 14 inches The
retinal images thcieby obtained are conespoud-
ingly larger, and thus reading may be continued
for a longer time than is otherwise possible
Rcidiug with a hand magnifying -glass also
sei\es the same puipose
The \anous operations performed for cataract
may be classed under three heads — (1) Itcchna-
tiou , (2) Discission , and (3) Extraction.
JReihntttwn 01 couching does not seem to be
practised m civilised countries It is a very
old operation, and the one which was at one-
time unncrsally employed The operation con-
sisted in pushing a needle, 'entered through the
solera, forwards between the lens and cihaiy
body, and then, by raising the handle, pushing
the cataiactous lens backwards into the vitreous
This operation, though producing necessarily,
in uncomplicated cases, an immediate restora-
tion of sight, was abandoned owing to the fre-
quency with which it was followed by inflam-
mation or glaucoma It must be lemembered,
however, that rcclmation was performed exclu-
sively in the pre-antiseptic i>enod Indeed, not
only weio no antiseptic precautions taken, but
some of the descriptions given of the operation
make it clear that it was custoiuaiy for some
operators to dip the cataiact needle into, or
smear it with, substances which were more
likely than not to be septic The nsk of re-
clmation nowadays could certainly not be nearly
so great as it foimerly was. Nexerthcless, as a
surgical proceeding, it is mfeiior to discission or
extraction
Diwssion consists m opening the anterior
capsule with a fine, sharp cataiact needle, and
then passing the needle deeper into the sub-
stance of the lens and stimng it up The
aqueous humour is then hi ought into direct
contact w ith the substance of the lens, which is
macerated, driven forward in flocculent masses
into the anterior chamber, and ahsoibed. The
absorption takes place through the channels, at
the angle of the anterior chamber, by which the
aqueous leaves the eye If the discission has
been free, flocculent masses of macerated lens
matter icadily escape out of the capsule and
he in the antenoi chamber There they gradu-
ally become lessened in size as absorption slowly
proceeds
In performing discissiou care must be taken
5
66
CATARACT
to make a sufficiently large opening m the
capsule. When the lens is stirred up the swell-
ing which takes place as it becomes macerated
leads to an extrusion of some of its substance
through the capsule wound into the anterior
chamber. If the wound in tho capsule is not
large enough, as is, for instance, the case if the
capsule has been merely punctured before the
lens has been stirred up, tho mtracapsular
swelling which follows may cause more or leas
irritation of the eye due to increased intraocular
tension. Apart fioin this, however, absorption
does not under these circumstances take place
so readily, or it may stop altogether Tho
operation has then to be repeated
The cataract needle in performing a discisuon
should be passed very obliquely through the
corneo-scleral margin into the anterior chamber,
thus forming a valvular opening After having
reached a little beyond the middle of the
chamber, the capsule should be lightly cut by
raising the handle of the instrument till the
point of the needle comes in contact with it
The needle point is then drawn over the surface
of the capsule, and made to tear a linear
aperture in it The instrument is then slightly
withdrawn till its point lies again free in the
anterior chamber, then again pushed m suffi-
ciently to enable another section of the capsule
to be made in the same \vay, but in a direction
crossing the first at as great an angle as
possible. In other words, tho capsule should
be opened by a pretty free crucial incision which
does not pass too deeply After this is done the
needle is pushed into the lens and stirred about
Care must be taken not to perforate the posterior
capsule, which may readily be done towards the
periphery where the lens is thinner
The operation of discussion done with an
aseptic needle causes very little reaction
Absorption, however, takes place very slowly,
seveial months elapsing befoie the pupil is
clear Occasionally aftei three or four days
glaucomatous symptoms may develop In
children this is often accompanied by sickness,
and tho oyo becomes congested and painful It
is then necessaiy to lehevo the tension by ex-
tracting some of the macerated lens from the
eye This is done through an opening made at
the corneo-sclnral margin \vith a bent keratome
Tho lens matter is lemoved thiough this in-
cision along a curette (a small grooved instiu-
ment made foi this purpose), \vith which the
outer lip of the wound is depressed, and which
is introduced a shoit way into the anterior
chamber
This operation of linear piecemeal extraction
is very often made to follow a discussion oven
when no symptoms of irritation have super-
vened Tho removal of the cataract is thus
hastened. When properly performed, and with
due antiseptic precautions, it is a perfectly safe
proceeding
Operation by discission with or without a
subsequent linear extraction is only suitable for
cataract m young people. Different operators,
lomever, recognise different limits of ago, after
hich discission should not be done It w,
'onorally speaking, not advisable to operate in
;his way when tho patient is more than twenty-
ive Too much irritation is otherwise apt to
je caused by the harder central portions of tho
ions In any case the later a discission is done
tho more necessary is it to follow it up with a
linear extraction As a rule it is better to
perform the extraction at once, and not subject
the patient to two opeiations.
Discission followed by linear extraction is the
most satisfactory opetation for lamellar cataract
m childicn It is also the operation generally
porfoimed foi traumatic cataract in young people
Extraction of the opaque lens as a whole from
the eye is the method of operating which still
remains to be described Theie are several
different methods of extraction m use These
methods mainly ditfei in minor details The
general pimciple of cataract extraction is to
remove from the eyo as completely as possible
tho whole of the mtransparent lens in a mannei
which is conducive to rapid primary union of
the exteiual wound made tor tho purpose The
wound must not only occupy a position which
does not interfere 011 cicatrisation \vith \ision,
but it must be so placed that the edges ho m
good apposition after the cataract is removed,
and are also readily uouiished The site
usually chosen for the wound is therefore the
corneo-sclcral margin Some operators, how-
ever, carry the incision more or lens decidedly
into the cornea
The operation of extraction is performed with
a long nar low knife, the so-called Grwfe knife
Tho incision into the eye is preferably made
along the upper coriieo-scleral margin, where it
is afterwards mostly covered by the upper lid
In making the incision the knife is entered at
the outer side at a point in the cornoo-scleral
margin on about a level with the horizontal
tangent to a semi-dilated pupil This is what
is generally called thepunctwe The knife is then
carried rapidly across tho anterior chamber, and
a counter puncture made in the inner and upper
corneo-scleral margin at a point just opposite to
the puncture The incision should ho through-
out in the corneo-scleral margin, and should be
made with as little sawing motion as possible.
The wound should, in fact, be as clean-cut as
possible, and occupy about one -third of the
corneo-scleral margin If the extraction be
combined with indectomy a poition of iris is
next excised, the ins being drawn out through
the incision either with ins forceps or hook, and
then snipped across with a pair of sharp ins
scissors When the hook is used this can be
done without causing any pain After replac-
ing the edges of the wound (coloboma) in the
CATARACT
67
iris, should they be caught at all in the external
opening, the capsule is ruptured with the cysto-
tome The incision of the capsule is made in
different ways by different operators The
main point, howevei, to attend to is that it
should be sufficiently free This is best effected
by scratching the capsule several times, so as to
make sure that the cystotoinc is not merely
moved on the surface of the lens below the
capsule without enlarging the opening first
made in that membrane The cataractous lens
is then caused to become engaged with its upper
edge in the external wound This is done by
pressure on the lower half of the cornea When
it has thus become engaged, further pressure,
followed by gliding the scoop used for the
purpose upwards, caubes the lens to escape out
of the eye Particular care must next be taken
to replace any iris that may be caught in the
ends of the incision This is best done w ith a
soft caoutchouc or tortoise-shell repotttor. In
the process of delivery it usually happens that
some of the soft cortical portion of the lens is
rubbed off and remains in the eye Subsequent
gentle pressure on the cornea, which is most
conveniently made through the lid, enables one
to get rid of this The pressure causes the
external wound to gape slightly, and at the
same time rubs the cortex tlnough it Before
applying any dressing it is necessary to make
sure that the lips of the wound aie in good
apposition, and that they do not entangle any
capsule or cortex The icpositor should bo run
along between them, so as at the same time to
flatten out any flap of conjunctiva which may
have been cut in making the incision
When extraction is pcrfoimcd \vithout mdcc-
tomy, what is called the simple as opposed
to the combined extraction, the external wound
has to be made slightly larger The pressure,
too, must bo rathei greater, as the lens has to
pass in front of the iris, which necessitates also
making the wound gape to a greater extent
In this operation cortical remains aic removed
with the curette, and nut by pressure, after the
ins has been carefully replaced, should the
pupil not of itself have recoveied its circular
shape
THE QUESTION OP IRIDECTOMY OR NO IRIDEP-
TOMY — Whether thfc simple or the combined
operation is to be preferred is ono upon which
much has been said, and one upon which different
surgeons hold different views Tho advantages
of the simple operation are, that no wound is
made in the ins, that the cosmetic effect of a
round pupil aimed at m this operation is better
than that of a coloboma even when the colo-
boma is made upwards, and that peripheral
attachments of the iris to the inner surface of
the external wound aie less common The dis-
advantages are that cortical remains aie not so
easily removed after the delivery of the lens,
and that prolapse of the ins into the wound is
more apt to take place than when indoctomy is
done In addition, the circular mobile pupil
aimed at is by no means always got Further,
the simple operation is not so easy, and on this
account alone not to be recommended to inex-
perienced operators There is no difference in
the result, so far as the acuity of the restored
vision goes, which is got" by the simple as
compared with the combined extraction The
simple extraction is in other respects, however,
the more ideally perfect one.
In making the somewhat larger section which
is required in the simple extraction there is some
difficulty often in preventing the ins from
falling m front of the knife as the anterior
chamber empties The blade must therofoie
be kept pushed well for \\aid, raising as it were
the comea from the chamber A miotic should
also be used immediately before making the
section, so that as soon as the ins is returned
tho pupil may be contracted The eye should
be examined from half an houi to an hour after
the operation is completed If the pupil at this
stage is found to be contracted and quite circular,
there is practically no danger of ins prolapse
taking place If, on the other hand, it is not
circular, but hitched up towards the wound, the
round movable pupil aimed at will not be got,
and there is in addition a strong probability
that healing will be impeded and more or less
unnecessary risk run by piolapse Under these
circumstances the best thing to do undoubtedly
is to perform an mdectomy at once, and there-
fore convert the simple into the combined ex-
traction This is very much more satisfactory
than any treatment of prolapse at a latei stage
in tho healing process In the experience of the
writer this abandonment of the intended simple
extraction is required in 10 pei cent of cases in
which it is begun In this respect, however,
individual differences must of course exist
This is haidly the place to discuss fully the
i dative meiits of the simple and combined
opeiations Some surgeons perform exclusively
the former, and some exclusively the latter,
whilst others again make a selection of cases
w Inch appear to them most suited for the one
or other method of operation
Tho wntei, after a \oiy extensive experience
of both operations, would, however, offer the
follow ing advice to lessexpeiienced operatois —
1 Do not attempt the simple operation at
all until sufficient experience of the combined
opciation has been obtained by the performance
of two or three hundred extiuctioiis
2 In the first simple extractions undertaken,
select cases of fully ripe cataract in, compara-
tively speaking, young individuals, say up to
the ago of sixty or sixty-five
3 Do not hesitate to abandon the simple
extraction aimed at whenever the conditions
above described indicate a risk of more or less
troublesome prolapse
68
CATARACT
It occasionally happens that \vhen the attempt
IB being made to remove the lens by pressure on
the cornea after the capsule has been nurtured,
vitreous humour presents at, or escapes by, the
external wound Pressure has then to bo
abandoned and the lens has to be taken out
with the vecti* This instrument, which con-
sists of a fine steel loop, is inserted behind the
lens by being gently forced past its upper
margin with a slight side to side movement
As soon as it has slipped far enough back it ib
pushed downwards so that the lens comes to
he upon it The vectis is then slowly with-
drawn with the lens, which is at first kept
pressed up against the back of the cornea until
it has so f<u escaped from the eye that it readily
comes away altogether. After this proceeding,
if the lips of the wound do not lie in good
apposition, the ins scissors should be used to
rut acioss any vitreous which protrudes
This accident may occur from want of caio
in the use of the cystotorne or by too great
straining on the patient's part The suspensoiy
ligament is then ruptuicd hi boine C<U>UH,
especially where the cataract is over-npe, it may
be impossible to prevent As it is a complica-
tion which cannot always be foreseen, a vectis
bhould always be at hand when perfoimmg a
cataract extraction
A considerable loss of vitienus may tike
place without impairing the result of a cataract
operation Yet there can be no doubt that with
the loss of vitreous, which is ncvei replaced, the
future of the eye is not so secure
Anothei complication which often calls foi
some modification of the method of operating ib
the co-existence of capsular cataiact When
the capmilar thickening is not \ci}? exteiisrve
the extraction may bo pei formed in the oidmary
way. With a large, dense, caphiilar cataract,
however, it is best to extract a portion of the
capsule instead of merely incising it before the
lenticular cataract la removed This is done
with capsule forceps, oi which there aic \arious
patterns Extraction of the portion of capsule
must be done carefully by gently moving the
forceps from side to side as it is being with-
drawn after having obtained a good hold of the
membrane.
AFTBII-TRBATMENT OP CATARACT EXTRACTION
— Though not absolutely necessary, it is a good
piocaution to take to keep the patient in bod
for two or three days after operation. This is
the best way of as far as possible securing rest
to the eye When this tioatment proves very
irksome, as it is apt to do in very stout or 111
diabetic individuals, it is better not to insist
upon it
With legard to dressings different ideas
obtain Some smgcous do not tie up the eye
at all Others apply borne sort of di easing and
bandaging, which is letamed for a varying time
afterwards. Others again tie up both eyes
Cataract extraction is an operation in which,
given a healthy eye, rigid antiseptic precautions
as regards the instruments used, and a certain
amount of skill, and particularly quickness in
pei forming the operation, the tendency to heal-
ing is fortunately quite remarkable On this
account it is practically impossible to justify
tiny claim of superiority for one method of after-
tieatment over any other which is not altogether
irrational The rule in such a case should be
to eri rather on the safe side It is theicforo
probably on the whole best to tie up the eyo
which has boon operated on for a few days
Three or foui days is sufficient The dressing,
too, may be changed once a day and the eye
examined at each dieting The surrounding
light should also not be excessive where it is
possible to control this The tying up of the
other eye does not seem to secure any greater
icst to the one operated upon, as the patient
instinctively keeps it closed foi the first few
houis until healing is suthciently advanced to
prevent movement gi\mg use to any pain As
in many cases, too, nuch treatment is found to
be very trying to the patient, it is letter to
avoid it
The only exception that should be made as
legardb tying up the eye after extraction IB
when there is an evident risk of infection from
local sources, as there is, foi instance, paiticularly
in patients sutfeimg at the same tune fiom
blcnorrhooa of the lacr^mal sac In these cases
it IH better to leave the eye altogether un-
covered Wheic this complication exists it is
also a good plan to dust freely finely powdered
lodoform on the wound immediately after the
operation is completed The purulent secretion
should subsequently be caiefully removed from
the lids two or thiee tunes in the twenty-four
hours by irrigation with an antiseptic lotion
In view of the usU of infection, too, the opera-
tion for a cataiuct which is complicated in this
way should be done as quickly as possible It
is especially impoitant that no prolonged effoit
should be ni.ulc to remo\e coitex, as every
moment and eveiy movement of the eye may
be supposed to inciease the chances of micro-
oigamsms settling in the wound
As a general rule the antcnoi chamber is
found to be le-foimed in a few hours after ox-
ti action, not infrequently indeed oven within
one horn This means that aftei so shoit a
time sufficient agglutination has taken place
between the lips of the wound to admit of the
letention of the aqueous humour The cleaner
the section and the more pei feet the apposition
the moi e rapid is this primary union Hence
the importance of a sharp knife and the absence
6f sawing movements in making the section, as
also the final cleaning of the wound
Very little reaction takes place as a rule
There is usually a little congestion merely of
the vessels in the neighbouihood of the wound.
CATARACT
This congestion increases slightly during the
three or four days that the wound takes to con-
solidate. Any f tirthei reaction is due to various
causes The most important is infection of any
kind during operation or from local sources
before healing has advanced Other causes are
the irritation of cortical lemains and antiseptics
introduced by instruments A superficial con-
junctival irritation often follows from too pro-
longed tying up of the eye or from the too
frequent use of antiseptic lotions
Of the Results of Infection the worst and most
dreaded is primaiy suppuration of the cornea
This generally leads to complete destination of
the eye Occasionally it stops short of this
either as the result of the local vital reaction or
of energetic and timely antiseptic measures An
infection of this kind usually shows itself within
the hist forty-eight hours after opciation, often
indeed within the first twenty-four hours The
patient complains of pain, the lids are red and
swollen, and on inspection of the eye a gieyish
infiltration is seen sti etching towards the centre
of the cornea from the wound An attempt
should bo made to check this at once as soon as
it shows itself This may bo done by applying
the thermo-cautery along the wound or by the
use of freshly prepared chlorine watei or of
pure liquid caibohc acid painted on the wound
with a fine camcl's-hair brush The wound may
then be dusted with finely powdered lodoform
and all dressings removed horn the eye If the
patient be old and feeble it is well also to use
stimulants ficely
Most cases of primary suppuration occur horn
infection which has its oiigm in the conjunctiva
or tear sac The cases most likely to go wiong
in this way are those complicated with hlenor-
rha?a of the tear sac, especially when this is
associated with blepharitis When theio are
no such evidences of local infection it is nearly
always the case that micro-organisms have been
introduced by the instalments In pre- anti-
septic times extraction failed fiom this cause in
a very much larger proportion ot cases than
now Yet even at the present time ptobably no
surgeon is able to steer free ot cornea! infection
altogether No doubt, therefore, there aic
exceptional cases in which the vitality of the
cornea is insufficient to withstand infections
which under ordinary cucumstanccH would be
counteracted With rigid antiseptic precautions,
however, not more than one eye in two hundred
should be lost in this \\ay where the surrounding
parts aie healthy at the time of opeiation
Severe attacks of iritis and irtdocycltto'i are
also set up by infection. Such cases seem to
originate, so far as is known, in the remains of
the lens tissue. Lens cortex has been shown
experimentally to be the most favourable tissue
m the eye for the growth of organisms. The
result of iritis when the inflammation remains
limited to the more anterior portions of the eye
is to leave a more or less dense screen, consisting
of ins, capsule, and hbnnous exudation, behind
which the vitreous may bo more or less infil-
trated The con ti action of the nitic exudation
often leads to a greater 01 less obliteration of
the colobomu, when an indectomy has been
pci formed, so that the pupil indrawn up towards
the external wound Occasionally an infected
iritis after cataiact extraction may lead to sym-
pathetic mischief (vide " Sympathetic Ophthal-
mitis ")
Lesser degrees of iritis are frequent They
do not cause any displacement of the pupil,
though some syneclnte form. They are probably
not of an infected nature, but caused mostly by
the irritation of remaining cortex
Glaucoma may also occur as a complication
of the healing piocess (vide "Secondary Glau-
coma")
A serious accident which sometimes occurs,
and which cannot bo foreseen, is copious bleeding
leading to detachment of the retina, which is
then often protruded through the external
wound This may occur any time within the
first twehe hours after operation Most
commonly it takes place almost immediately
afterwards. The eye has then to be enucleated
Only when the pupil is peifectly free from
cortical remains is the sight on pioper optical
correction as good twenty-four hours after opera-
tion as it eventually becomes AH a rule, owing
to gradual absorption of the matter left in the
eye, vision slowly improves, and only reaches
its maximum aftei, it may be, a good many
weeks
In by f.n the largest piopoition of cases the
best icsults, so far as the vision is concerned,
.u c only to be got by a second operation, which
consists of needhiKj the capsule This operation,
though very safe when pioperly done, should be
avoided whcnevei the vision is sufficiently good
others ise for all practical purposes Not only
is there some immediate risk attaching to it,
some chance of either inflammation or glaucoma,
but clinical evidence certainly appears to support
the view that an eye in which the vitieous has
been disturbed cannot bo regarded as quite so
safe as it would othciwiso be in all cases,
theiefore, the vitreous should be disturbed as
little as possible This is best attained by
making the desired opening in the capsule with
a single cutting needle 01 fine knife. The
instrument should be entered through the
corneo-scleral margin at a point which lies out-
side of the cuatm of the original extraction
wound Its point should then be passed
thiough the capsule at the opposite side of the
pupil and the cutting edge directed backwards
Finally, the handle of the instrument is raised,
causing the blade to sweep in the opposite
direction and cut an opening m the capsule
This should be done in such a way, too, as to
prevent the needle passing deeply into the
70
CATARACT
vitreous. In most oases where needling is done
in this way it may be done in the course of A
fortnight after the first operation. The capsule
is then elastic, and readily letracts bo as to leave
a gaping opening where it has been cut The
contra- indications to early needling are any
abnormal degree of reaction following the
extraction and the presence of much soft free
cortex
In cases whcie owing to nitis the pupil hap
been closed and drawn up \\ith the iris fibres
put on the stretch, the opening is best made
with a pair of small bcissois constructed for the
purpose (iridotomy scissors) An opening, which
should not be too small, ib made with a keratome
in the corneo-scleral margin and the scissors
introduced, with the sharp-pointed blade pushed
behind the ins and the blunt one in fiont As
boon as the blades have passed over to the
opposite side of the anterior chamber a snip is
made The cut, being at right angles to the
stretched iris fibres, admits generally of sufficient
retraction of these to maintain an opening In
the worst cases a bit of the opaquo screen has
to be cut out In all such cases, however, the
prognosis is less favourable
The large opening made in the eye for the
extraction of the crystalline lens causes, as might
be expected, some alteration in corneal curva-
ture. This operative astigmatism has to be
taken into account m detei mining the optical
correction after winds required for near and
distant vision It is some time — generally a
good many weeks — before the amount of the
astigmatism has become constant The piogiess
of cicatrisation leads to its getting gradually
loss and less for some time The final astigma-
tism varies in amount in different cases This
depends partly upon how the section has been
made and how healing has taken place, but albo
upon the previous state of the eye as regards
astigmatism. The operative astigmatism more
frequently counteracts than supplements a
previously existing astigmatism, as it is the
horizontal meridian of the cornea which is most
curved after operation When the factor of
pre-existing astigmatism is taken into account
it will be found that foi the same operator the
acquired astigmatism is much the same when-
ever healing has taken a normal course
One question remains to be coiibideied, viz
How far in the cabc of slowly developing cataract
is it nocesbary or advisable to \\ait until the
cataract is ripe before operating 1 This question
would no doubt be answered differently by
different surgeons The writer can only here
offer buch advice as his own experience leads
him to consider sound It has to be remembered
that many unripe cataracts, especially in old
people, can be extracted just as readily and as
completely as can ripe cataracts In many
cases, however, a good deal more cortex remains
in the eye. The cortex ib often not only less
readily removed but, being transparent at the
time of operation, cannot be recognised As the
time taken for the sufficient clearing of the
pupil depends upon the abborption of remaining
cortex, unripe extractions take on the average
somewhat longer before useful vision is restored,
while the risk of iritis of all kinds is proportion-
ately increased A much largei proportion,
too, require the second opciation of needling
Against these disadvantages have to be put
those of having to remain for years without any
useful degree of vision if one \vaits till a cataract
is ripe
An estimate of the relative impoitance of the
JMM and cows in this case can only be arrived at
by personal experience The following line of
action is suggested here —
1 Do not hesitate to operate on cataract that
is unupe, provided the patient has otherwise
healthy eyes and adnexa and the vibion is so far
i educed as to interfeie senously \vith comiort,
e tj makes the reading of ordmaiy type or the
following of the ordinary occupation impossible
2 Do not operate on unripe cataract of one
eye as long as the other eye retains sufficiently
useful vibion
3 Wait till the cataract is ripe in all cases in
which the risks of extraction from any cause are
evidently greater than usual
4. Do not perfoim prelmnnaiy nidectomy or
any other operation foi the aitincial ripening of
the cataract
The piactical result of following these ruleb is
that one operates on a much larger proportion
of unupe than of ripe cataract, but that when
one has to re-let the failure of the opeiation
f loin benous subsequent complications it is
mostly in cases in union there was not much to
l)e lost at any rate
CATARACT GLASSES — After extraction, the eye,
it previously emmetropic, becomes necessarily
hypennetropic The gla&s which then coirccts
for a distance when placed about 15 mm in
front of it is one of 10 0 or 11 0 dioptres That
is, in the condition of aphakia (abbcnce of the
crystalline lens) the previously emmetiopic eye
lias to be provided A\ith a glass lens of +100
to +110 m order to see distant objects
distinctly The retinal images then got of
external objects besides being sharp are larger
than they v\ ere provioiibly in the proportion of
about 32 If the eye \vore previously hyper-
metiopic a stronger lens \vould be required for
collection, eg if the degree of hypeimetropia
were 5 0 D, the glass after extraction \vould
require to be + 16 0 to + 17 0 If the eye were
previously myopic the correcting glass on the
other hand would have to be weakci, e g if the
previous dcgiee of mvopia were 5 0 D the lens
after extraction would have to be + 6 0 to +70,
if 100 D, +30 to +40, if 15 OD, +075 to
+ 150, if 200 D, -150 to -1-0 approxi-
mately. In the last case, therefore, the operative
CATARACT
71
hypermetropia would not altogether counteract
the previous myopia
With the absence of accommodation neces-
sarily following the removal of the crystalline
lens (vide " Accommodation "), a stronger glans
than that used for a distance is always required
for reading As a geneial rule the leading glass
should be about 4 0 D strongei , therefore in
the case ot pre\iously emmotropic eyes +140
to + 15 0. But this depends upon the distance
at which the individual roads With good
visual acuity he may prefer to use a weakei
reading glass Considerable alteration in focus
is also got by sliding the spectacles up and
down the nose, as their effect is stronger the
farthei they are removed from the eje In this
way what is tantamount to a certain range of
accommodation is practically obtained
Cataract lenses should always be ot glass, not
of crystal (pebble) Glass does not tiansmit the
actinic rays to the same extent, and these rays
a.e hurtful to the eye
Cataract lenses dimmish the held of vision
very materially On this account they should
be worn as large as possible, compatible with
not too great weight As a general rule the
best vision is only obtained with sphero-
cylindrical lenses, that is, lenses one surface of
which is spherical and the other cylindrical
This ih on account of the astigmatism already
icf cried to Sphere -cylimhical lenses are
necessarily heavier than oidmary bicomex
sphcucal lenses
When only one eye has been opciated upon
and the other is of little use, the spectacles may
conveniently be made reversible, i e the one side
provided with the distant and the other with the
reading glass
Cataract glasses should not be woni as long
as there is much cortex left to be absorbed In
any case it is iikuhuublo to use them sooner
than a foitnight after extraction. When used
soon they have often to be changed after some
months owing to the change which takes place1
in the amount of opciative astigmatism
Catarrh. — Inflammation of a mucous
membrane See BUONCIII, BRONCHI rw, BRON-
CHITIS ("Cataitfie sec"), HAY FEVER, INFLU-
ENZA , MBASI ES (Analysts of Symptom*, Catarrh)
NOSE, AcurB INFLAMMATION (Acute Jthiniti
or Cotyza), NOSE, CHRONIC INKLAMMAIION
STOMACH AND DUODENUM, DISEASES (Gastritis)
Catarrhe Sec (Laennec).— Dry
chronic bronchitis, with severe paroxysms of
coughing See BRONCHITIS (Clinical Varieties)
Catarrhus
FEVER
EstlVUS. See HAY
Catarrhus Com munis. See NOSE
INFLAMMATION (Caryza)
Catarrhus Epldemlcus. See
NFLUENZA.
CatarrhUS FerlnuS. See WHOOPING-
COUGH
CatastaslS. — Constitution , habit of
>ody, restitution or the diminution in the
seventy of the symptoms of axlisease (in contrast
to paroxysm)
* Catatony.— A psychosis, described by
Kahlbaum, characterised by cramps, tctanoid
igidity, catalepsy, melancholia, and stupor, it
resembles melancholia attouita and general
alybib of the insane See KAIAIONIA , SLEEP,
FORMAL A\D MORBID (Aim bid Somnolence)
Catchment Area.— That part of a
mer basin from which lam is collected, usually
for the purposes of watvi -supply
Catechu, foe ASTRINGENTS , DIARRHOEA,
FiiAiiMACoi o(,i , PRESCRIBING — Pale catechu
(obtained from Uncarta (famlier) is an astrin-
gent extiact, which contains catechu-tanmc acid,
catechuic acid or catechm (C21lI20Og), and pyro-
catcchin or catechol (C0H4(OH)2) It is power-
fully astringent, and is given in doses of 5 to 15
gr , it is incompatible with gelatin, alkalies,
and metallic salts Its preparations are Pulvis
Catechu Ctunjiositut (dose, 10 to 40 gr.) , Tine-
tut a Catuhu (dose, £ to 1 fl dr ), and Trochiscus
Catti/in The lozenge (containing 1 gi of
catechu) is a favourite remedy for sore throats
]tt<ick Catechu (Acacia Catechu) is not official in
the Bntish Phaim.uopwia
Caterpillar Rash. See RUBELIA,
ROSERASII (Diagnosis fioni Catetjnllcu Rath),
DERMATITIS TRAUMAUCA ET VENENATA (Causal
Agents, Animal) t MYIAHIS (Hany Caterpillars)
Catgut. See ASEPTIC TREATMENT OF
WOUNDS (titcnl i nation)
CathflereslS. — The feebly caustic action
of u substance1
CathartlCS.— Diastic purgatives, such
as calomel, jalap, aloes, scammony, colocynth,
and croton oil, which produce a violent action of
the bowels, usually attended with griping and
sometimes followed by considerable prostration
vSome of them (e <j elaterium and scummouy)
cause a copious wateiy flow, and are called
hydtaqoyue tire alto CONS IIPAI ION , PHARMA-
COLOGY , PRESCRIBING , and under the \anous
dings Cathar^s is the name given to the effect
which cathartics produce (literally, cleansing)
CathelectrOtonUS.— Whenagalvamc
current is passed through a nerve that structure
is found to be alteied in condition at the poles ,
this altered state is called electrotonus, and the
special condition of increased irritability found at
CWngtiu's llultow l)ftut«?y.
CATHETERS, USES AND DANGERS OF
73
useful when there is a dilatation at the bulb or a
median enlargement of the prostate Force is
quite inadmissible , the instrument must find its
own way. If tho catheter is a ngid one the
change in tho direction of tho urethra as it
winds under tho pubos through the triangular
ligament must be txjrne in mind, and care must
be taken to depiess the handle sufficiently.
False passages, \vhun they do not begin in front
of a stricture, always start from this point, and
generally run upwards and backwards between
the prostate and tho bowel If the finger is
introduced into tho rectum the least deviation
can be detected at once In cases of enlarge-
ment of tho prostate an English gum-elastic,
which has been kept tor some time over-curved
upon a stilet, sometimes succeeds when others
do not , or Key's well-known plan may be tried
of passing the catheter down to the obstruction,
withdi awing the Htilet, and at the same time
gently pressing the instrument onward. In
stricture cases a catheter with a very long and
fine whip-like end lieyond tho eye will sometimes
find its way Small metal catheters require the
gicatest care, as the points arc very sharp and
the walls of the urethra veiy tondoi When the
object is to diaw oft a largo amount of lesidual
urine, and it is essential to prevent any organ-
isms being earned into the bladder, an instru-
ment like Mclchior's should bo used This
consists of two tubes, one gliding inside tho
other The outer is of metal, and is sufficiently
long to reach tho membianous portion Its
vesical end is ( loscd with a film ot rubber held
in place by a metal cap As soon «is this M in
position, a smaller flexible ono is pushed do\vn
through it and through the rubbei film directly
into the piostatic uiethia, HO that tho cathctci
which enters tho bladder is inner bi ought into
contact with the meatus or tho mucous mem-
brane of tho anterior portion of the urethia
PAIN AND SPASM — The urethra is exceedingly
sensitive, especially the deeper portion The
passage of an instrument through this is always
accompanied by pain and sometimes by syncope
All instruments must be warmed Under the
mucous membrane is a stout layoi of uiistuped
muscular fibre which often gups tho catheter
firmly, and prevents it for a time from being
pushed on or dra\vn back, but the contraction
always tiros itself out in the course of a few
minutes A preliminary injection of a few drops
of a 2 per cent solution of cocaine will prevent
both pain and spasm
The passage of a catheter, especially for tho
first time, is liable to bo followed by conse-
quences, some of *lnch, such as syncope and
shock, are referable to the reflex action of tfo
nervous system, while othois are due to the intro-
duction of septic organisms into the deeper part
of the methra and the bladder.
SYNCOPE — Syncope is not uncommon, and
may be serious if in an old man a large amount
of residual urine is suddenly allowed to stream
out through a full-sized catheter while he is
standing upright Shock is rarely grave or
general, but local shock, due to inhibition of
some of the nerve centres in the lumbar portion
of the spinal coid, is not at all uncommon. It
may show itself by ictention from inhibition of
tho centro which controls the jtct of micturition,
or by hcematuna from congestion of the kidneys
due to teinpoiary vasomotor paralysis, or even
by suppression of urine As the cause is a very
transient ono the effects ncaily always subside
without any active measuies being necessary
SEP nc POISOVING — Tho effects which are due
to tho introduction of septic organisms may be
either local or general Tho former include the
inflammatory affections of the urethra, bladder,
epididyims, and prostate, which are so often met
with after careless eatheteiism, the latter com-
prise the different forms of what is miscalled
catheter or urinary fever Tho bacillus coll
is the most common septic organism, but the
staphylococcus aurcus, citrous, and albus, the
streptococcus pyogenes, and the bacillus urese
liquefaciens are all of frequent occunence, alone
and togethet They may enter the urinary
passages through tho blood -stream or the
lymphatics, invading the walls first, or they
may come down from tho kidneys in the unne,
or ascend upwards from the meatus (especially
in the case of \\omen) , but when febnlc attacks
occur after tho introduction of a catheter, tho
organisms which cause them arc nearly always
carried in on the surface or in the eye of the
instrument It is for this reason that sterilisa-
tion is so important
The smallest fotm of urinary Jevet is a ngor
or shivering fit, due to absoiption through some
abtasion (or perhaps e\en thiough the unbroken
surface of the urethra) of the toxins which have
been formed by septic organisms growing in the
uiethia It begins as a rule, not when the
catheter is passed, but some houis later, after the
first act of micturition All of a sudden tho patient
is seized AN ith intense prostration and chilliness,
which is desciibed as being felt inside The skin
becomes rough and livid The faceis pinched The
jyos look sunken, and are surrounded by dusky
rings Tho respiration is hurried and shallow,
and the pulse small and frequent From the
first moment, even when tho teeth are chattering
and the patient sniveling, the temperature
begins to rise, and it continues through the
period of dry, burning heat which follows until
sometimes it i caches 106° F In ten minutes
01 half an hour, according to the severity of the
attack, profuse perspnation sets in, the face
becomes flushed, the involuntary muscular fibre
in the skin relaxes, and there is a sensation of
profound relief although the patient is utterly
exhausted
Rigors do not occur oven after such operations
as internal urethiotomy if care is taken to render
74
CATHETERS, USES AND DANGERS OF
the instruments, the untie, and the urethra
aseptic. They are more rare after operations
upon old and dense cartilaginous strictures than
after those upon recent ones, not because the
germs are fewer, but because in the former
absorption is not so easy They occui, as a
rule, not when the catheter is patted, but after-
wards at the first micturition, because the passage
of the urine down the methra raises the prcssuic
and forces into the circulation the toxins \vhtyh
have been formed m the interval They seldom
occur after external urcthiotomy, because owing
to the open wound there is no pleasure Aftei
lateral lithotomy they are very rare, even when
the urine is septic, for the same reason And
the same thing explains what has been so often
noted, that, while every attempt at dilating a
stricture causes a rigor, free urcthiotomy or
rapid and complete stretching cures the patient
at once without the least reaction
Theio are, of com be, accessory causes Any
slight chill aftci an operation upon the urmaiy
organs, such as standing with bare feet upon
cold oil -cloth, will precipitate a rigor, and
patients who have been exposed to malaria are
especially predisposed to such attacks But
these are not necessary, and there can be no
doubt, from what has been learnt by expeii-
menting upon animals, that the toxins arc
perfectly efficient by themselves, even though
the amount which is driven into the en dilation
is infinitesimal
The prognosis in this form of urinary toxseinia
is good as a rule In some, fortunately veiy
rare, cases the collapse has been so severe that
the patient has never rallied This is iccoidcd
as having happened even after the passage of a
catheter, but most of the cases have followed
operations upon the kidney for septic pyehtis
The explanation is that the manipulation of the
kidney during the opetation forces into the open
ends of some ot the renal vouules such a large
amount of the toxins which have been lying
stagnant in the pelvis that the nerve centres arc
simply overwhelmed Even when there arc two
or three rigors in succession there is no great
cause for alarm It usually means the absorption
of successive doses Hut when the rigors continue
after forty-eight houis, after the surface of the
wound in the urethra has been glazed over, it
becomes a question whether the oigamsms them-
selves have not entered into the blood-sticam as
well as the toxins, whether it is not a case of
septic infection rather than of simple toxaemia
True septic infection may, of course, occur after
operations upon the urethia as after operations
upon other parts of the body. There are no
local symptoms, but the rigors recur again and
again, generally irregularly, but sometimes with
intervals as regular as in ague The patient
rapidly becomes weaker and thinner. Perhaps
slight jaundice sets in There may be an attack
of diarrhoea with peculiarly offensive motions.
The pulse becomes more and more frequent, and
at length death ensues from exhaustion.
Another and equally common form of what is
called urinary fever is more chronic and much
more insidious The most typical examples are
met with in cases of enlargement of the prostate
at the beginning of catheter life, especially in
those in whom there is a large amount of
residual urine A catheter is passed and the
bladder partially emptied This is lepeatcd
once or twice a day for several days Theie is
no rigor or other symptom of note The urine
is clear, but the specific giavity is low, and the
amount unduly large On the fourth or fifth
day the bladder becomes irritable, and the urine
is found to be a little tin bid, so that after stand-
ing a grey deposit of pus settles at the bottom
of the vessel The total amount may increase
until it reaches seven 01 eight pints a day, or it
may dimmish The reaction is generally faintly
acid, but it rarely fails to become alkaline after the
first few days There are often a few hyaline casts,
and sometimes there is a little albumin Thcic is
no rigor though the patient may complain of feel-
ing chilly. The temperature only uses one or
two degrees, but the pulse increases in frequency
and diminishes m strength , the tongue becomes
diy and brown, especially down the centre , the
appetite is lost, thcie is a tendency to nausea ,
the mind becomes a little unsettled, and then
mutteiing del mum begins at night, and the
patient sinks into what is called a typhoid state.
Post-mortem the bladder may be found to be
large, with thin walls, or small and rigid, \sith
thick ones, and perhaps sacculi projecting from
them, but there is always evidence of recent
acute cystitis The ureteis aie dilated and full
of oilensive urine and pus. The pelvis of the
kidneys is in the same condition The mucous
membrane is discoloured, with flakes of pus
adhering here and there The apices of the
pyramids arc eroded The kidneys themselves
are small and hard, and on section are seen to
be studded with minute abscesses differing in
shape and outline according to the anatomical
arrangement at that particular spot In a word,
there is evidence eveij where of long-standing
disease of the bladder and kidneys with, in
addition, recent septic inflammation and sup-
puration The symptoms aie not duo to shock
caused by emptying the bladder. They are in
part the result of chrome renal insufficiency, in
part of septic poisoning The fault is in the
bladder not being emptied properly A ceitam
amount ot mine, a liquid m which micio-
oigamsms grow exceedingly well, is habitually
left stagnant in its recesses Day by day more
and more organisms are introduced by the
catheter, and at last septic cystitis and pyelo-
nephritis result
Treatment — Nothing special need be said
about syncope or shock when they follow the
passage of a catheter or any other operation
CATHETERS, USES AND DANGERS OF
75
upon the urethra Retention of urine can often
be prevented by a subcutaneous injection of
strychnia given at the time of the operation
If it follows in spite of this a catheter mubt be
passed again, but not until it is clcai that there
will bo no relief without Suppression must be
treated by subcutaneous injections of digitahn,
cupping over the loins, hot baths, and puiga-
tives
So far as what is commonly called unnary
fever is concerned, the mam treatment is pre-
vention All instruments should be sterilised
beforehand, and only touched with hands that
have been rendcied thoroughly aseptic The
patient's bowels should have been well opened,
preferably by a purge containing calomel, and
the urine should have been rendered as resistant
as possible to living organisms by the admmis-
tiation of intestinal antiseptics for home days
beforehand Salol and naphthalm I believe to
be the two most efficacious, but the former
should not be given in doses larger than three
or four grains at a time, for fear of forming
intestinal con ciet ions The patient should
remain quiet for some hours after the operation,
even if it has been incicly the passage of a
catheter (unless he IH accustomed to it), and
great care imibt be taken to avoid anything that
might cause a chill
The bladder should be emptied at the time
of the opciatiou, and micturition postponed for
as long as the patient conveniently can There
will then be less nsk of absoiption A hot hip
bath just before tho first a<-t of micturition
lessens the chance of a rigor, not only by its
action upon the skin, but by tho way in which
it causes all tho unstriped muscular fibre
around the u re tin a to relax, and so lessens the
pressure as the mine is driven down At the
same time the patient may be given a cup
of hot tea, with some brandy, opium, and
quinine
It is piobably impossible to lender the mucous
membrane of the urethra leally aseptic, certainly
if it is inflamed , but theie is some <td vantage,
1 believe, in washing it out thoioughly before
such an operation as internal urethiotomy, cither
with a sat mated solution of boracic acid or with
nitrate of silver, one in a thousand After a
stricture has been divided in this mamiei I
always inject on to tho face of the wound twenty
drops to half a drachm of a J per cent solution
of nitrate of silver 01 of piotargol, and leave it
there The same thing should be done at tho
neck of tho bladder in e.ises in which a large
amount of residual urine is evacuated It
certainly checks, if it does not absolutely pie-
vent, the growth of septic organisms at the
critical place and time
If a second rigor occurs after internal ure-
throtomy or any other operation upon the
urethra, the injection should be repeated, and
a catheter tied in so that the bladder may be
kept permanently empty for forty-eight houis.
This renders further absorption almost im-
possible. It is not wise to leave the catheter
longer than forty-eight hours, for fear of causing
urethritis
If tho bladder becomes irritable, or if any
deposit of pus makes its appearance after the
evacuation of residual urine, /the same thing
should be done , and in addition, if tho state of
th« bladder will allow it, tho bladder itself
should be washed out twice a day with conosive
sublimate or nitrate of silver. If this does not
succeed very soon, or it it is evident from tho
shape of the piostate, or the condition of tho
bladder, that it is riot possible to keep the
cavity empty by tying a catheter in, there
should be no hesitation m adopting penneal
drainage or even puncture through the prostate.
If septic cystitis is allowed to continue, pyehtis
and pyelonephritis will follow The most
successful way of stopping inflammation of the
bladder is to follow the plan adopted by nature
so far as it can, and empty the bladder and
keep it empty The danger lies in leaving a
collection of urine, which has become converted
by septic organisms into a virulent poison,
stagnant in the post - prostatic pouch The
wisest plan is to adopt adequate measures while
there is yet time
Very little can be done in these cases towards
restoring tho aseptic character of tho urine by
means of drugs Unhappily, intestinal anti-
septics have very little influence upon the urine
They may make it less favourable as a nutrient
medium for the giowth of organisms, but the
amount that reaches the urine thiough the
kidneys is not sufficient to kill organisms which
have already established themselves And it
must not be forgotten that the majority of
patients who are attacked by this form of
urinary fever aie already enfeebled by long-
standing renal inadequacy, and that anything
which tends to upset their digestion, or prevent
their taking sufficient nourishment, is more
likely to do them harm than good Quinine,
boi ic acid, salol, and naphthalm are the drugs
which I have found most useful, but tho patient
must not be forgotten while the complaint from
w Inch he is suffering is being treated
Cathetometer.— A tathetci gauge for
ascertaining the calibre of the instrument
Cathode. — The negative pole of a galvanic
battery , the negatno eloctiode
CattlVQ Male. *S'ce PELLAGRA
Cattle. <SVe ABATTOIR*, ANTHRAX,
DAIRIES, FOOT AND MOUTII DISEASE, RHEU-
MATISM, CHRONIC (Comparative Pathology) ,
TUBERCULOSIS , etc — From the Public Health
point of view, cattle includes bulls, cows, oxen,
heifers, and cahes, while the term mumal is
76
CATTLK
applied to cattle, sheep, goats, all other rumi-
nants, and swme In Scotland, however, the
former term includes sheep, goats, and swine
Cattle Plafflie. — A markedly con-
tagious disease, charactenscd by fever, catarrh
(nose, eyes), cessation of rumination, constipa-
tion, etc ; rinderpest Kee I\niuvm (Cuttle
Plague)
Cauda Eqillna. — The bundle 01 leash
of nerves arising fiom the spinal cord «it the
level of the second lumbai vertebra, and
including the (onus mcdullana 01 teimmal part
of the cord itself *SV?e SPINAL CORD, MEDICAL ,
SPINAL CORD, SURGICAL , etc
Caudate Nucleus. *%« BRAIN,
PHYSIOLOGY, PHYSIOLOGY, NERVOUS SYSTEM
(Cetebtum)
Caul. — If dining labour the fatal mem-
branes (ammon and chonon) or one of them
(amnion) fail to iiipturo till after the head ot the
child is bom, or if the i upture take place high
up inside the uterus, the infant is born " with a
caul," i e with the head enveloped in the mem-
branes, the silly how or cajmt gal cat am *SVc
LABOUR, FAULTS IN THE PASSENGER (Membranes,
Toughness).
Cauliflower. *%« INVALID FKEDINC,
( Vegetables)
Causalffla. — Neuralgia, accompanied by
a burning sensation *SVe NERVES, NEURALOIA
CaU8l8.— Cautoi isation
ZBSIOCAUSIS
e ATMOCAUHIS ,
CaustlCS. — Substances which, when ap-
plied locally, kill the tissues with \\hich they
come in contact and set up inflammation m the
surrounding parts, eschaiotics, instances aie
found in mine <ind sulphuric acid, m caustic
potash and caustic lime, m catholic acid, and in
arsemous acid (7 v.) lion at a icd heat also
acts as a caustic, as does the galvano-eautery
See CAN^UOIN'S PASTE, CAUTERY, CEsopiiAous
(Inflammation) , TOXICOLOGY (Cotiosivei) , etc
CauteretS. See BALNEOLOGY (Fiance,
Sulphui) , MINERAL WATERS (tiulp/uited)
Cautery. See alw CAUSTICS , GALVANIC
CAUTERY; HEMORRHAGE (Cautei isation) — There
are three varieties of cautery (1) The actual
cauteiy, the application points being usually
hatchet-shaped, globular, or flat, (2) thermo-
or Paquelm cautery, the terminals being straight,
curved, knife -like, pointed, or flat, and (3)
galvano-cautery
HEAL AT WHICH LAIPWYED —This may be black,
red, or white hoat, and \anes according to the
object of its use.
BLACK HEAT —The cautery is used at black
heat as a counter-irritant This is useful in
many chronic affections of bones, joint*, and
serous membranes, such as spinal memnges,
pleura}, bursw, tendon sheaths, in chrome con-
ditions of ipinal cotfl, nerve*, especially inter-
costal neuralgia and sciatica It is also of
service m hysterical conditions, with localised
painful areas, and in cases ot malingering.
RED HEAT — It may be used at a dull or a
blight red heat (1) At a dull ted heat the
cauteiy is used as a severer foim of counter-
irntaut in the conditions mentioned previously,
and also as a haemostatic m cases of haemorrhage
where a ligatme cannot bo applied, eg bleed-
ing from bone or tooth sockets, or oozing from
a large surface, 01 in hicmophilic subjects
Occasionally it is required when tracheotomy
has to be perfoimed through a veiy vasculai
growth
(2) At a bught ted /teat it is not applicable
as a hu?mostatic, the eschar being too weak
It is useful, however, as a severe counter-initant,
and also tor touching hstulous openings, e </
uicthra, lectum, umbilicus, salivary ducts, with
a view to encouraging them to close Phage-
dwnic sores and the surface of poisoned wounds
are often much benefited by its use It is also
employed tor the icmoval ot urethial caruncles,
prolapse of the lectum, growing capillary muvi,
ensoul aneurysm, and also ignipunctuie ot
hypeiti opined tonsils The employment ot
the cauteiy foi the removal of tumours is now
abandoned
Win IE HEAT — This is applicable in all the
pioMously mentioned conditions, except where
the htemostatic action is desired It is the
most useful heat to employ wheie tissue has to
be punctuied to some depth, as in ignipuncture
of tuberculous glands, as it ictams the heat tor
a longer time Negieth has lecommcndcd its
UHO m hypeitiophy ot the prostate, the gland
being punctuied fiom the lectum
71KCH\iQUh — 1 Actual Cautet y — When black
heat is to be used the button cauteiy, 01 Corn-
gan's button, is the toiin employed, a latch key
making a good substitute When the cautery
has been heated in the flame of a spirit-lamp
until the metal shaft close to tho wooden handle
becomes so hot that it only allows of momentary
painless touching with the finger, it should bo
rapidly tapped ovei the painful areas For
led ot white heat the cautery is placed in a
tire, and on removal is applied whenever its
tempeiatuie has reached the (leaned limit
The hatchet-shaped instrument is used for linear
cauterisation, the parallel lines being drawn at
a distance of about one inch apait. If the flat
form be used it is drawn over the surface at the
late of about one inch a second For heernor-
ihage the bleeding surface is steadily scared by
rubbing the cautery over it, otherwise the
instrument may adhere, and in its removal
separate the eschar, and the haemorrhage may
CAUTERY
77
he again started. If tho bleeding point is in
bone or the socket of the tooth, a knitting-
needle at red heat bored against tho point acts
well
2 Nherrow Cauteiy or Payuelm'* — Before
use the instrument should always be carefully
tested, special attention being paid to the
following pointb — Tho benzolmu reservou
bhould bo only halt filled, and the bcuzolme
bhould be fresh, as it rapidly loses tho active
and moie volatile portions The blade should
1)0 heated icd-hot in a spu it-lamp, and then
the vapour pumped in Should it not work,
most probably the bcnxolme is at fault, <ind the
heat of the hand over the reservoir may be
necessary to distil ovei some active vapour
It IH used in the same way as the actual
cauteiy, but has one gieat advantage, that is,
when it becomes adhcient to the tissues the
temperature can be laised and the cautery
removed without detaching the eschar Aftoi
use tho blade should be allowed to cool and
then be dned In ignipunctmc for a painful
spine, the skowci -shaped cautery is pushed
through the skin over the lateral soft tissues,
and nisei ted about J to \ of an inch The
punctures aie made about one inch apart
The Dccheiy automatic cautery is anothei
vanety of the thei mo-cautei y Here ether is
used instead of bcnzolme, half an ounce being
sufficient foi ini ty minutes' incandescence This
is a u>iy convenient and portable form of
mstiumciit
PRACTICAL POINTS is inn AFPLICATIOV — (a)
When the cauteiy is employed at icd 01 \vhitc
heat a qenual (invent Jtctu should be adminis-
tered, and if ether be used gioat caie must be
adopted lest the inflammable vapoui become
ignited by the cauteiy
(h) If the constitution of the patient is en-
feebled by anaemia, Blight's disease, diabetes,
melancholia, 01 other cause, the use of the
cauteiy at ted 01 \vhitc heat should be avoided,
tho icpaiatne power of the tissues being much
diminished Foi the same icason it ought not
to be used, if fiom disease or fiom injury the
trophic power of a pait is impaired
(c) Atea of Application — All hauy paits
should be shaved, and the suiface rendered
aseptic All open surfaces, as soics, fistula:,
should be dned, and any blood -clots present
icmoved. If the cauteiy is to be used for
localised tendei s])ot8 they should be maiked
before commencing tho application Soft parts
with thick skin aic the most suitable sui faces
for application
When superficial, all bones, neives, tendons
should be avoided , also the trachea and urethra
In brunettes, the neck, arms, and face aic
better avoided, as permanent pigmentation may
re&ult.
(d) THE LOCAL RESULTS — The effect at first
IB very painful, especially when red and white
heat have been applied The application of the
cautery produces burns of various degrees at the
point of application, and " radiation burns " in
the immediate neighbourhood The eschai
following burns ot the thud and fourth degree
may take soveial dajs to sepaiate When the
cautery has been employed as a h<emostatie,
tho separation of such eschars aie apt to be
followed by hemorrhage Aftei ignipuncture
the, healing may be veiy slow
AtTRn-iHKAiMFNi — If there be much pain
anodynes internally may be given, except in
hysterical patients and malingerers
In burns of the fiist and second degree a
weak antiseptic ointment spread on lint is all
that is requncd (nee " Burns")
In sevcior foims of burn cold boracic corn-
pi esses relieve the pain If delay in the heal-
ing is desired, ung sabui.e two parts to vaseline
one 01 two paits should be nibbed in once a
day, and if tho pain so induced be very great
2 per cent to 1 0 poi cent i ocamc may be added.
The eschai being aseptic does not interfere with
tho healing of a wound by primary union The
disagreeable odour of binning flesh may l>e
pai t Lilly concealed by the fumes obtained fiom
placing the red-hot cauteiy in some ground
coffee
Caver nit i8. — Inflammation of the eioctile
tissues (cot pot a cavernow) of the penis *S'ee
P*,MS, SLKGICU, AFIJICTIONS op IIIK (Inflam-
mntoty Affiction*)
Cavernous Breathing. *v« LUNG,
TuiihRCULOhis (Physical »S*/r/M* of Vonuca For-
mation)
Cavernous Sinus. Me BRMN, Pm-
MoixKiY (Vtnmn Cncu/ntion)
Cavities.— Hollow spaces in the body,
open 01 closed, e y abdominal, ammotic, buccal,
cotyloid, cranial, nasal, peiitonoal, pleural,
tympanic, and uterine cavities, also patho-
logical foimations, as in the lungs in phthisis
(»ee LUMJ, TunMtruixMtih OF)
Cayor Fly. — An insect found m Afnca,
Ihe lar\<e of which apparently causo boils
CebOCephalUS.— A iaic teratological
type, closel) i elated to cyclopia, m which the
two oibits aie approximated (but not fused), the
nose deformed, and the whole face diminished
m si/e The evpiession of the face is ape-like
(KV/fos, ape, *€</>aA»/, head) The biam shows
tho same malformations as in cyclopia
Celerlna. — A preparation, said to contain
celery, coca, kola, vibuinum, and aiomatics,
which is recommended as a nerve tonic and anti-
spasmodic in cases of neurasthenia, neuralgia,
dysmenorrhoea, otc
Celery. #<?e INVALID FEEDING ( Vegetables).
CELIBACY
.— The unmarried rtate ; suicide
common among celibates than among
i married. See SUICIDE
are prohibited as dwell-
ings by the Public Health Aot (England and
Wales) of 1875, with cerUm exceptions care-
fully specified in the Act. The Public Health
(Scotland) Act of 1897 contains similar re-
strictions
CellOtfOpln.— One of Merck's prepara-
tions, obtained by the action of bcnzoyl chloride
upon arhutin, of which it is the monoben-
zoylester , it is used (m doses of 5 to 8 grains)
to protect the system from infection (by the
formation of alexmes)
Cells. tiee PHYSIOLOGY, THE CELL, PHY-
SIOLOGY, THK TISSUES (Epithelium, Connective
Tissue, Muscle, Nerve)
del III lit IS.— Inflammation of the areolar
tissue See ANEURYSM (Complications, Cellutitu
and Suppuration), AXILLA, DEBASE* (Acute
Cellulttis) , BURBJS, INJURIES AND DISEASES
(Bursitis, Acute), CuEsr-WALL, AFFECTIONS
{Acute Cellulitis and Alsces*) , MENSTRUATION
AND DISORDERS (Dysmenvrrhuea from Pelvic
Cellulitis), MUMPS (Local Affections, Cellulitis
of Floor of Mouth) , NECK, REGION OF (Inflam-
matory A/ecttons) , ORBIT, DISEASES OF (0? fatal
CeUulitu or Phlegmon), PELVIS, DISEASES OF
THE CELLULAR TISSUE (Pelvic Cellulitis) , PELVIS,
HAMATOCELE AND H^MATOMA, SPERILITY
{Causes), TEETH (Alveolar Abscess), UTERUS,
DlBPLACEMBNTS OF, UTERUS, NON- MALIGN ANT
TUMOURS (Diaynons)
Celluloid.— An artificial substance con-
sisting chiefly of the lower nitrates of cellulose
m camphor, and used as a substitute for ivory,
bone, etc , its great inflammability and con-
sequent danger have been diminished by the
addition of sodium and ammonium phosphates,
etc , xylonite
Cellulose.— -The chief component of
vegetable structures, a carbohydrate of un-
ascertained constitution (CbH10O6)n, cotton-wool
is almost entirely cellulose , nitric and sulphuiic
acids act upon it to form gun-cotton and celluloid
CelOSOmuS. — A teratological type m
which there is eventration of both the abdominal
and thoracic organs through an opening (lateral
or median) affecting the walls of both cavities
(thorax and abdomen), the sternum is defect-
ive It is derived from rtfa, a hernia, and
, body
Cement. See PHYSIOLOGY, TISSUES, TEETH
(Anatomy)
Cementoma. — A fibrous odontoine
which has 'ossified into a hard; cement -like
tissue. See TUMOURS (Odontomata, CenutUoma).
Cemeteries.
CREMATION.
BUBLU, -
CenCSStheslS.— The vague conscious-
ness of existence which exists apart from the
special senses and is due to general impressions
of bodily conditions , the name is derived from
KOII/OS, common, and o«r^rts, sensibility, an-
other spelling is Coencesthests
Census. — The decennial enumeration of
the population of Great Britain (last was in
1901), in order to obtain a basis of facts for the
science of vital statistics and for other reasons
The mean population is that at the centre of
the year, and since the census is taken at the
end of the first quarter, it has to be corrected
for the three months which follow, to give the
true mean population of that year The census
paper has to be filled up by the householder giving
name, ago, sex, occupation, birthplace, relation-
ship to head of the house, married or single
state, infirmities, etc , of the various people who
slept in the house on the census night It
would probably be well to have the census more
frequently taken, m order that the birth-rate and
the death-rate, etc , should be more accurate
Centimetre. <&<? MBFRIC SYSTEM
Centipedes. >SVe NOSE, FOREIGN BODIES,
BIG (Pataiitet, Entonwzoai w.)
Centres. *SW BRAIN, PHYSIOLOGY, PHY-
SIOLOGY, TUB SENSES, PHYSIOLOGY, NERVOUS
SYSTEM, PHYSIOLOGY, CIRCULATION (Vaiomotor
Centt g«) , PHYSIOLOGY, RESPIRATION , PHYSIOLOGY,
DioBsrioN (Vtnnitiny Centre), etc
Centrifuge. — A rotatory apparatus by
means of which centrifugal force is used to
separate solids from a liquid, e g milk or urine
CentrOSOme.— A spheiical body, some-
times two, found m the protoplasm of many
cells, from which rays diverge, they play a
part in imtotic division of the cell. See PHY-
SIOLOGY, TUB (JKLL
Cephalalff la.— Headache, of various
kinds, such as catarrhal, congestive, dyspeptic,
epileptic, febrile, hysterical, menstrual, muscular,
neuralgic, ocular, poiiodic, rheumatic, syphilitic,
etc See under the various diseases
Cephalhasmatoma.— A blood effu-
sion (usually in the new-born infant) between
the pericranium and one (or two) of the under-
lying cranial bones, to this form of tumour
the term should be restricted, although it is
often loosely applied to the caput succedaaeum
and to an effusion of blood inside the cranium
(the so-called internal cephalhcematoma). See
Cephaloeele.
CEPHAL1LEMATOMA
79
BRAIN, SURGERY OF (Cephalocele, Diagnosis)',
HEAD (Cephalhcematonia) , NEW-BORN INFANT
(Cephalhamatoma Neonatorum)
Cephalic.— Belonging or relating to the
head, as in such expressions as cephalic index,
cephalic lie (head presentation), cephalic teta-
nus, cephalic veision, etc. See ANTHROPOLOGY ,
LABOUR, DIAGNOSIS AND MECHANISM (Presenta-
tions of the Vertex) , LABOUR, OPERATIONS
( Version) , TETANUS (Clinical Feature*, Cejthaltc
Type)
Cop h aline. — A substance derived from
the brain, related to lecithmo.
Cephalitis. #«• BRAIN, INFLAMMATION
(Encephalitis)
CephalO*. — Ocphalo-, occurring in many
compound words, means relating to the head
It is used in many anatomical terms (e q cephalo-
napal, ccphalo-hu moral), and in such words as
cephalocentesis (puncturing the head, as in
hydrocephalus), cejthalograph (an instrument for
indicating cranial contours), cephalomelus (a
teratological type in which a limb appears
to spring from the head), and rephalopyow
(cerebral abscess), as well as in several names
specially dealt with below
Cephalocele. — The swelling (skm-
covered) formed by the protrusion of part of
the cranial contents through a more or less
rounded opening in the cranium, and it may be
congenital or acquired *SVe BRAIN, SURGERY OF
(Cephalocele) , TERAIOLOGY
Cephalodyn la.— Headache, usually of
a rheumatic and muscular type
Cephalometei*. — An instrument, usu-
ally a pair of callipers, for taking the moasuie-
mentH of the head, a modified apparatus has
been invented for gaining an idea oi the dia-
meters of the foetal head before birth (foetal
cephalometry) , a cramomoter
CeptialOpaffUS.— A double moustot,
or twins united to each other in the region of
the head
Cephaloplne. — An extiact of bram
substance.
Cephalothoracopag us.— A double
monster, or twins fused together in the regions
of the head and thorax a* far .is the level of the
umbilicus.
CephalotOmy.— An obstetric operation
(for diminishing the si/e of the child's head)
proposed to be' earned out by saw-forceps or
wire-ecraseur , obsolete tiee LABOUR, OPERATIONS
(Embryotomy).
Cephalotrlpsy.— An obstetric opera-
tion in which the foeCal head is crushed by a
pair of strong forceps (the cep/tnlotrtbe) capable
of being approximated by a screw at the handles.
See LABOUR, OPERATIONS (Embryotomy) t LABOUR,
PROLONGED (Contracted Pelvis, Tteatment)
Cera. — Wax Two forms are employed (as
a basis for ointments and plasters) in the Bntish
Pharmacopoeia, Cent Flava (yellow beeswax) and
Cera, Alia, (\thito beeswax), the latter being
obtained from the fonner by bleaching Cera
consists chiefly of en otic acid (C27H64O2) and
mehwyl (or myncyl) palmitate or myricm, with
a small quantity of cerofeine, and with paraffin
and cerevne as impurities
— An insoluble gum from the
cherry, peach, or plum tree, it resembles
bassonn, and is (chemically) calcium metagum-
rnatc
Cerastes. — The "Horned Viper" of India
Xee SNAKE-BITES AVH POISONOUS FISHES
Cerates. — The cerates (cetata) are oint-
ments containing \\ax, and they are official iri",
the U S Pharmacopoeia Goulard's cerate is
now represented in a modified form (m the B P )
by the Unsjuentum Glycerim Plumbi Sitoacetatis
Xee PRESCRIBING
Cercomonas. /^PARASITES (Protozoa,
Flayellate)
Cereals. — Edible grams, such as wheat,
oats, bailey, and rye >S'ce DIET (Vegetable
Food*) , PHYSIOLOOI, FOOD AND DIGESTION
( Vegetable Food-tituffi)
Cerebellum. »V«s BRAIN, CEREBELLUM,
AFFECIIONB OF iStf alto BRAIN, PHYSIOLOGY,
HRUN, SURGERY (Abuce**); H\ DROCEPHALUS ,
LUNG, TtBEiiCULOhiH (Complications, Nervoux
tiyrtem) , MENTAL DEFICIENCY (Atrophic Con-
ditwnt) , PHYSIOLOGY, NERVOUS SYSTEM (Cere-
helium) y TABES DORSALIS (Diagnosis) , VERTIGO
Cerebration.—" The assemblage of the
ceiebial actions consecutive on a perception"
(Lewes) Unconscious cerebration or latent
thought (Hamilton) is a ceiebial or mental
action occurring during bleep or during the time
A\ hen the attention is otherwise occupied
Cerebrln. — A substance obtained from
biam tiBhuo (by boiling first with baryta solution
and then with alcohol) said to have the formula
ot C^HjyNOg
CerebrltlS. *SW BRAIN, ATROPHY, IN-
FLAMMATIONS (Encfphalitu)
CerebrOSlS. — Inflammation or irritation
of the brain , mama
Cerebrc-Splnal Fever. ^MENIN-
GITIS, EPIDEMIC CERBBRO-SPINAL
so
CEREBRUM
Cerebrum. See BRAIN, PHYSIOLOGY,
BRAIN, AFFECTIONS OF BLOOD-VESSELS, BRAIN,
TUMOURS, BRAIN, ATROPHY, HYPERTROPHY,
CYSTS*, INFLAMMATIONS, BRAIN, SURGERY OF
See also under ALCOHOLISM , ARTERIES, DISEASES
OF; ATHETOSIH, BED-SORES, FLUIDS, EXAMINA-
TION (Cerebio-Spinal) , GOUT (Irregulai, Neivvus
Syitem) , HEAICI, MYOCARDIUM AND ENDOCARDIUM
(Symptomatology, Embolic Ptocess), HYDRO-
CEPUALUS , INSANITY , PATHOLOOY OF , LYMPHATIC
SYSTEM, PH\SIOLO&\ (Cential Netvout System),
MEN^OBS OF THE CEREBRUM , MENIMJI i is, TUBER-
CULAR, MENINGITIS, EPIDEMIC, MENTAL DEFICI-
ENCY, NOSE, ACCESSORY SINUSES, INFLAMMATION
(Intra-Ctamal Complication*) , NOSE (Cerebto-
Sjnnal Jihinorthvea) , PARALYSIS, PHYSIOLOGY,
CENTRAL NERVOUS S\STEM, PNEUMONIA (Com-
plications), RHEUMATISM (Netvous A/ectionv) ,
SPINE, SURGICAL (Lumbar Punctme) , SYPHILIS ,
TABES DORS VLIS , TEMPERATURE (Net vow Oiiyiri),
TETAVUS , TEI'ANY , UNCONSCIOUSNESS
Ceresole Reale. Sec BALVEOLOG\
(Italy, Chalybeate ami Att>enica/)
Cerium.— The oxalate (Cent Oxala*) is
official, and w given in doses of flora 2 to 10
grains, especially in the vomiting of pregnancy ,
it is insoluble in \\atci See PREGNANCY, AFFEC-
TIONS AND COMPLICATIONS (Digestion)
"Cerolln." — A propnctary picparation,
called 111 England teridm, said to contain the
active principle of beei yeast, and to do good in
boils and acne, etc , it is given in pill fonn
(dobP, 1J giam)
CerotlC Acid. — An oxidation product of
paiaffan, pi od need by prolonged boiling with
sulphuric acid and solution of bichromate of
potash , its formula is
Certification. See INSANITY, TREAT-
MENT, LUNACY, MEDICAL PRACTITIONER,
MEDICINE, FORENSIC (Certification of Deaths).
Cerumen. — The secretion ot the external
auditoiy mcatus and of its ceiummous glands,
it contains potash, oil, steal in, a i eddish pig-
ment, etc , and it prevents the easy passage of
insects into the ear, oar-\vax See EAR, EX-
TERNAL, DISEASES OF (Abnormal Mates of the
Cerumen) Excess of the cerumen (and its
lesults) is called cenimmom
Cervical. — Belonging to the neck, eg to
the vertebral column in the region of the neck,
to structures in the same neighborhood, or to
the neck (cervix) of the uterus In compound
words it appears as cervico, e g ee» vico-brachial,
tetvico - l»e<jniatic, cervico - vayinal, etc tfee
ACROMEGALY (Cervical Xypliosis) , BRACHIAL
PLEXUS (Man/teal AJfectums of), LYMPHATIC
SYSTEM, PHYSIOLOGY AND PATHOLOGY, NERVES,
NEURALGIA (Get vico- Occipital) , S\ RIXGOMYELIA
(Paralyse of Cervical Sympathetic); UTERUS,
INFIAMMATIONS (Cervical Catarrh)
Cervix. — The neck-like part of any organ
or structure, eg ceivix uteri (qv tnfta)t cervix
femons, cervix vesico)
Cervix Uteri. *SV? (IRNEU \TION, FEMAI E
ORGANS or (Uterut) See alw AIJOHTION (Treat-
ment, jKevtiamtof H<r tiiot i htifle) , CHORE A (Choi ea
Gtavidatum, Tieatment) , GONORRHCLAL INFEC-
TION (Endocervicitn) , (}\ NKCOI.OOY, DIAGNOSIS
IN , LABOUR, PHYSIOLOGY OF , LAHOUH, STAGES
AND DURAl ION , LABOUR, MANAGEMENT , LABOUR,
PRECIPITATE AND PROLONGED (Faults in tJie Soft
Patsaqe*) , LABOUR, INJURIES TO TUB ( JEN E RA-
TH E ORGANS , LABOUR, OPERATION'S , MENSTRUA-
TION AND ITS DihouDKRh (Stenow of the Cetvuc,
etc), PELVIS, PERINEUM AND PELVIC FLOOR
(Prolapse) , PREGNANCY, PHYSIOLOGY , PREG-
NANCY, AFFEPTIONS AND COMPLICATIONS ( Voaut-
m<?) , PREGNANCY, HEMORRHAGE (Accidental,
Placenta Ptwvia, Plm/(/ing) , PUERPERIUM,
Infection, J/MCOHS 7*^117 in Cetvix) , STERILITY
(Cauw, Cei wc<t( Atiebia) , S\pmr.ib (Acquit ed) ,
UTFRUS, MALI'OKMATIONS , UTERUS, DISPLACE-
MENTS, UIERUH, INFLAMMATIONS, UTERUS, NON-
MALIGNAM TUMOUUS , UTERUS, MALIGNANT
TUMOURS
Ceryl. — A hydiocarbon xadicle (C27Hr>5),
cetyl altohol ((JJ7HfiliOli) IH obtained from Chinebe
wax (ceryl cerotatc, C04H108O2) by sajxmifying
it, cetylene (C^H^) is got (tiloug with ceiotic
acid) by the distillation of the sumo subsUnce
(Chinese wax)
Cesspools. See SEWAC.E AND DRAINAGE
(Ce8»])ools) , TYPHOID FEVER (Etiology, Seicage
Emanations)
CeStOdeS (Cestoldea). See PARA-
SITES (Ceitode*)
— Cetaceum or Spermaceti is
a bohd ciybUlhne fat, obtained (mixed with oil)
from the head of the Physete/ mactoiepfialus or
sperm whale , it conbi&ta of cetyl palniitate or
cetine (ClbH31C10H8102) , by bapomfying it, cetyl
alcohol or ethal (ClflHSJOH) is got, Cetaceum
it> insoluble in water, but soluble in cthei, chloro-
foim, 01 alcohol (Iwihng) The official prepara-
tion is Ungucntum Cetacei, and it is used in the
making of ointments See PRESCRIBING
Cevadllla. See VERATRINL
Ceylon Sore Mouth. See SPRUE
Chain. See EHRLICH , IMMUNITY , etc
Chalazlon. See EYELIDS, AFFECTIONS
OF (Glandi of the Lids). — A tumour developed
m the eyelid due to inflammation of one or
more Meibomian glands fiom blocking of the
CHALAZION
81
ducts and retention of bocretion , the contents
in some cases become chalky (cluilazion terreum) ,
Meibomiau cyst
CtiallCOSlS. — Pneumonokomosis due to
the inhalation of sihcioub particles See LUNGS,
PNEUMOVOKONIOSIS
Chalk. See CALCIUM (Calcium Cat bonate) ,
GOUT (Morbid Anatomy)
ChalleS. tire BALNEOLOGY (Fiance,
Turned, Sulphur), MINERAL WATERS (*SW-
phated)
Chalybeate Waters. — Mineral
waters containing iron, useful in antenna,
chlorosis, debility, etc See CHLOROSIS (Treat-
ment) , MINERAL WATEIW (Chalybeate)
ChamCBCephaly.— The shape of head
in which the vertical index is less than 70 1°
(or 75°), a low, flat head, due to maikcd
syuostosis of the tempor.il hones with the
panetals , platycepbaly Similarly, chamcppro-
sopic is the term applied to a faro with a small
zygomatic facial index, a low face
Chamomile. See ANTHEMIDIS FLOBKH ,
PHARMACOLOGY , PRESCRIBING
Champetier dc Ribes' Bag. See
LABOUR, OPERATIONS (Ituluction of Premature
Labour), PRFONANCY, HEMORRHAGE (Unavoid-
able Hwmonhatfe, Treatment)
Champignon. /See TOXICOLOGY (Funyi)
Chancery. See LUNACY (Chancery
Lunatics in England)
Chancre.— The initial lesion (or "hard
sore ") of syphilis, especially when in its classical
form (as desciibud by Huutci), the name is
sometimes given <ilso to the simple or non-
infecting venereal sole >SVe SYPHILIS (Mode* of
Infecttnn, Acquit*!, etc) , HERPES (Herpes Geni-
tals), VENERKAL DISEASE
Chancroid. — The simple, non-infecting
venereal sore , the bimple chancre , the soft
sore See PENIS, SURGICAL AFFECTIONS (Herpes
Proffemtaln) , SkiN, BACTERIOLOGY (Chanctoid,
titteptobacillui of Ductey) , VENEREAL DISEASE
(Differential Diagnosis)
Change Of Life. See MENOPAUSE,
MENSTRUATION AND ITS DISORDERS (Menopause)
ChapS. — Cracks or fissures of the bkin (e g
on the hands in cold weather, or round the
nipples during lactation), known also as iivna>
or rhayade* , they are to be tieated by careful
drying after washing, by inunction of glycerine
or hazelme cream at bedtime For cracked
nipples see PUERPEUIUM, PATHOLOGY (Sore
Nipple*)
VOL. II
Charas. — A resin obtained from the
leaves of Indian hemp , chwrus. See CANNABIS
INDICA
Charbon. See ANTHRAX, BOILS AND
CARBUNCLE
Charcoal. See CARBO. f
Charcot's Disease. See JOINTS,
DISEASES OF (associated with locomotor ataxia) ,
ANKLE-JOIN r, DISEASES OF (Tabetic Arthropathy),
HIP -JoiNr, DISEASES OF (Diagnosis, Chircot's
Diieaie) , HiP-JoiNT, DISEASES (Neuro-Arthro-
jmthies) , KNEE-JOINT, DISEASES OP (Neuro-
Joint*) , TAIJLH DORWALIS (Tabo-Arthi (qxithies)
Charcot-Leyden Crystals.— Octa-
hedral crystals found in the sputum in at»thma
("asthma crystals"), and in the blood in
leukaemia See BLOOD (Examination, Special,
Micto-Cfiemical)
Charple. — Old linen, unravelled , used
for surgical dicssings
Chart. — A piinted form ruled with spaces
foi exhibiting in a graphic way ribcs and falls
of tcmperatui es, changes in pulse -rate, etc.
See TEMPERAIURE
Charta. — A paper covered or imbued
\vith a medicinal substance, and used as a
plaster The ctutrta vnajm (mustard leaf) is
official See PRESCRIBING , SINAPIS , etc
Chart U la. — A small paper folded to con-
tain a medicine in the form of a powder , rice
paper may be used
Chasm US.— Yawning See PinsioLOGY,
llEM'iRAi ION (Special Jf expiratory Movements),
YAWNING
Chatel • Guyon. See BALNEOLOGY
(Ftance, J/vunted Water), MINERAL WATERS
(Mm tatetl Saline)
Chaudfontalne.
fan<7 and Aelaium)
See BALNEOLOGY
Oil. — Oleum Cyno-
caidup or Oiaulmoogra oil is not official in the
British Pharmacopoeia, but is so in the Indian
and Colonial Addendum of 1900 , it is expressed
fiom the seeds of Cfynwardta odorata or of
Gynoiardia 1'tanui , it contains chiefly gyno-
c&rdic acid and glycerule , and its dose (given
in capsules) is 5 to 20 m In the Indian
Addendum there is also an official Unguentum
Gynocatduf It has been much used, internally
and externally, in leprosy See LEPROSY,
(Treatment).
Cheeky PlSSUre Of. See also TERA-
TOLOGY (Face) — Definition — A malformation of
82
CHEEK, FISSURE OF
the lateral portion of the face, consisting in a
cleft affecting the poft paits, or more larely
invading aJso the bones, arising during the
embryonic period of antenatal life, and caused
by delayed or irregular closuie of the fissuies
between the ft on to-nasal and stipcnoi maxillary
and the mandibular piocesses
Vanetie* — From the anatomical as well .is
from the pathological and embryological stand-
points fissures of the cheek may be divided into
three kinds (1) fronto-maxillary, (2) coin-
missural , and (3) anomalous
The ftonto-nutetllaty, ascending, oblique1, or
naso-genal hssuio begins at a point in the upper
lip just outside the common site of hare-lip, and
passes upward* outside the nostril towards the
inner angle of the orbit , it may there produce
coloboma of the lower eyelid, and it may, in
exceptional cases, extend to the outer angle of
the orbit and even on to the temple It is
nmlateial or bilateial, simple or complicated ,
it varies in width fiom a narrow cleft to a gap-
ing opening , it usually has a red floor and red
irregular maigins, but it may at one or more
places present a cicatucial appearance (ante-
natal partial cure?) When the underlying
skeleton is also hssmed the line of cleavage
does not exactly follow the suture uniting the
upper maxilla to the bones ot the nose , gcnci-
ally the mtcrmaxilla can y ing the incisor teeth
is internal to the fissure, but occasionally a
precamno incisor is found external to it, a
peculiarity not yet satisfactorily explained
The complications arc the presence of other
facial fissures (hare-lip, comimssural cleft of the
same or of the opposite side), deformity of the
eye or eyelids, cerebral hernias and hydro-
cephalus, and the more distinctly teratological
conditions of anencephaly, excncephaly, and
adhesion of the placenta 01 ammotic membrane
to the face or brain It is veiy tare m animals
(mammals)
The comrmwwal, intermaxillary, or trans-
verse fissure of the cheek (maciostoma, hiatus
buccahs congenitus, conmussiiral hare -lip, or
coloboma of the cheek) diffcis in direction fiom
the fronto-maxillary variety , it passes from the
buccal commissure backwards, with an inclina-
tion upwards tow aids the masseter, and even
when it proceeds fuithci it rarely invades either
the orbit or the external car It may be uni-
lateral or bilateral, simple or complicated, and
of great or little extent When it is bilateral
and extensive the mouth is converted into an
opening reaching from one ear to the other
In the less marked degree the defect lays bare
one or two molar teeth at the angle of the
mouth The opening of S tenon's duct can be
seen in the upper margin of the cleft The
zygomatic arch may be cleft as well as the soft
paits, and the upper maxilla may be small or
deformed Although it may occur as a solitary
malformation, it is more common to find it
associated with such anomalies as pre-auricular
appendages (in eighty-seven cases of pro-auncu-
lai appendage collected from htciature sixteen
showed also cornmissuial fissure, v Tetatoloyta,
11 p 31 , 1895), microcephaly, or hemi-
atrophy of face or cranium, frouto - maxillary
fissure, deformity of the external car, cleft
palate, macroglossa, and exencephaly In
animals (lamb, calf, pig) it is, on account of its
extent, a gra\c condition, foi the mouth may
communicate with the tympanic cavity , it is
called schistoccphalus megalostomus
Anomalous fissures of the check which do not
follow the lines of the natuial embiyomc clefts,
but which pass, for instance, from the angle of
the mouth to the inner cud of the orbit, or
obliquely across the face from one side to the
other, have been put on iccord It is probable
that they are usually the result of an ammotic
adhesion, the othci two vanctics being due to
simple pressure from an impeifectly developed
amnion
Symjttonuitology — In addition to the obvious
defoimity caused by fissuies of the cheek the
symptoms of the comiuissuial vaiicty m paitu u-
lar consist in imperfect closure of the mouth,
dribbling of saliva, and difficulty in mastication
and articulation Infants exhibiting this de-
formity are often small, weakly, and poorly
nourished, and may be defective in intelligence
T> eat merit has almost invariably consisted in
the closure of the fissure by paring and uniting
by sutures its maigin Gencially the opeia-
tion has been quite successful
Cheese. tiee DIET (Milk nnd it* 7'tn-
ducti) , PHYSIOLOGY, FOOD AND DIUEOTICW (Milk,
Cheew) , TOXICOLOOY (Anittml Fowls, Cheese) ,
TUBERCULOSIS (Tubercle awl Butter Racillu<*)
CheilO-. — In compound woids cfiedo- (Gr
X«iAos, the lip) means relating to the lips,
among such words may be named c/teilojtlobti/
(icstoration ot the lips to their normal form and
continuity by opeiation, vide PALATK, HARE-
LIP), cheihbchwi (haie-lip), cheilocarcinonui
(cancer of the lip), etc
Chelr-. — In compound woids chetr- (Gr
X<t/>, the hand) means i elating to the hand ,
instances arc found in chew omega? i/ (giant
growth of the hand), ihfirat/ra (gout in the
hand), cheitoKjxtmiui (ciamp in the hand), chen-
wgta (surgery), etc.
ChelrOpOmpholyX. See ECZEMA
(Iteyionul Fotma, //cinr/s) , SKIN, BACTERIOLOGY
OP (Chetroponipholyx or Dyvdtosia)
Chelold. See CICATRICES (Keloid or
Cheloid] , SCLEUODERMIA (CircumsM ibed)
ChelOnlSOmilS.— A teratological state
in which there is eventratiou of the abdomen
and thorax and excessive retroflexion of the
body , turtle-like monstrosity (hence the name
CHELONISOMUS
83
chclouisomus, from x'Auity a turtle, and
a body) , schiatowmw reftxus (Gurlt)
Chelsea Pensioner. — The name
given to a laxative, containing bulphur, rhubarb,
bitartrate of potash, guaiac, honey, and nut-
meg ; used specially m cases of hteniorrhoids
Cheltenham. Xee BALNEOLOGY (Great
Btitnin, Chalybeate), MINERAL WATERS (Mun-
ated Saline)
Chemical Trades. #«• TRADES,
DANGEROUS (Chemical)
ChemoslS.— (Kdematous swelling of the
conjunctiva oi the eye, which is thus laiscd and
caused to project over the edge of the cornea
*SVe CONJUNCTIVA, DISEASES OF (Acute Ophthal-
mia)
ChemotaxIS.— An attraction or affinity
of one tibsuo for a similar tissue, e <j of nerve
for 1101 \c , also the power of a tti action or re-
pulsion which some cells (or some constituents
of cells) show as icgards othci cells
.— The gooscfoot, several
species of winch have been used for their
medicinal qualities , the oil of the fruit of C
ambiociotdc* is official in the United States
Pharmacopoeia, and is used <is a vermifuge,
other species are used as diuietics, emmena-
gogues, narcotics, etc
Cherry Laurel. &e DERMATITIS
TRAUWATICA El' VbVRXATA ( Vegetable Agent*}
Chest. See A our A, THORACIC, ANEURISM
{Physical tiH/ns) , ASTHMA (tiymptomi) , CHIL-
DREN, CLINICAL EXAMINATION (Physical Ex-
amination of Clievt) , MEDIASTINUM , MEDICINE,
FORENSIC (Infn nticide) , S\ uiNcunn KLI A (tfymjt-
toinv, Tlionif en bateau} , vide infta nndet
<JHESU, CLINICAL EXAMINATION, CHK.sr, DR-
FORMIIIES , CHEST, INJURIES, CHEST -WALL,
AFFECTIONS OF
Chest, Clinical Investigation
Of the. — In the clinical investigation of the
chest the observer may gam much valuable
information by a geneial suivey of the patient,
the appearance, expiession, attitude, etc , before
turning to the direct investigation of any cardiac
or pulmonaiy derangement which may be sus-
pected (Physiognomy) Yet the physiological
functions and pathological alterations of cardiac
and pulmonary organs are so intimately associ-
ated that it is impossible for an observer to
differentiate how much of the patient's altered
appearance and attitude may be due to dis-
turbance of the functions of respiration and how
much to distui banco of the circulatory organs,
unless a careful physical examination of the chest
be made, fully investigating the condition of the
lungs and heart
In examining the chest it is necessary to have
the patient as far as possible at rest, with
the limbs and trunk symmetrical and the light
falling equally upon the parts under examina-
tion
INSPECTION —FORM o* CULS>T — Normal — It
is not common to meet the ideal typical chest,
with a well-developed almost 'symmetrical bony
frame, well clothed with muscle, fanly rounded
on tho anterior aspect, the interspaces visible
below but not above, the obliquity of the ribs
increasing from above downwaids, and the
epigastric angle nearly a right angle Many
alterations are met which cannot justly be
considered pathological, thus as the result ot
occupation, e </ the depiession at the lower end
of the sternum iound in shoemakers During
health tho respiratory and circulatory move-
ments aie accompanied by ceaseless changes in
the outlines of the chest With full inspiration,
full expansion of the chest, the axes of the
ellipse become approximately equal and tho
hori/ontal outline Incomes more circular The
framework of the chest is shortened from above
downwaids, tho ribs are raised and approach
the horizontal plane, the mtei costal spaces are
narrow anterioily, the epigastric angle is wide,
the sternum is carried forwards and upwards,
the shoulders aie raised, and the scapuUc are
closely applied to the chest-wall Such is tho
chest of lull inspiration With full expiration
the trans veise axis of the ellipse maikedly
exceeds the anteio-posterior, the ribs aio de-
pressed, the framework of the chest is lengthened
from above downwards, the intercostal spaces
ai e wide anteriorly, the sternum passes down-
wards and back \vaids, the shouldeis aie low,
and the scapular angles project somewhat from
the* chest-wall Such is the (host of expiration
While these changes m the outline of the chest
are constantly going on m health, in disease
the same changes octiu m an exaggerated
degree In disease and deformity there may
be an increase 01 diminution in the length or
height of the bony framcwoik, an alteration m
the hori/ontal position of the ribs leading to an
alteration in tho axes of the ellipse, an increase
or diminution in the width of the intercostal
spaces, m the size of the epigastnc angle, in
the position and direction of the sternum and
spine, in the height of tho shoulders and the
position of the scapuhc, and all these factors
have a definite relation to the outline ot the
horizontal plane of tho chest, and it is by the
study of the outline of the hoi izontal plane that
the observei will get the best idea of the altera-
tions in tho chest in disease and deformity
The outline of tho homontal plane of the chest
is best ascertained by means of the cyrtometer
Tho best idea of the shape oi the chest can be
got by taking the outline at a given point with
the cyrtometer Various elaborate instruments
are to be had, but a very good cyrtometer can
CHEST, CLINICAL INVESTIGATION OF THE
be made with two bars of malleable metal con-
nected posteriorly by means of a rubber hinge
The two bars, being moulded round the chest,
and their point of intersection marked, they
can then be detached and placed upon paper
and an accurate tracing obtained The out-
line of the adult chest is seldom symmetrical
Employments which cause individuals to assume
certain positions or to use a certain set of
muscles constantly are very prone to cause
variations in the shape of the chest, without
these variations having any direct pathological
significance The circumference of the right
side is, as a rule, larger than the circumference
of 'the left, in a small number of cases the left
is the larger In the adult the lateral diameter
exceeds the antero-postenor , in the child the
chest is more circular in form, the two diameteis
being about equal
Alterations in Size and Shape, etc — In
emphysema the chest presents a characteristic
appearance, the neck appears shortened, the
shoulders elevated, and the back rounded,
there is a bilateral increase of the chest, the
outline tending to assume the circular form
seen m childhood The chest is often de-
scribed as " barrel-shaped " In the " alar " or
"phthisical chest" we find sloping shoulders,
prominent thyroid cartilage, deep hollow over
the episternal notch, and prominent scapulae
Here the antero-posterior diameter in the upper
two-thirds is much shortened, and instead of a
convexity there is usually flattening The ribs
tend to slope downwards instead of coming for-
ward in a normal curve
Unilateral increase of a general character is
met «ith in effusion into the pleura Localised
increase may arise from acute croupous pneu-
monia, tumours of the lung, and mediastmal
growth Marked increase over the lower and
right side of the chest should suggest the possi-
bility of some hepatic affection, while on the
left side the spleen should be rcmembeied In
cardiac enlargement, especially when the en-
largement has developed during childhood, there
may bo marked bulging or increase in the pre-
cordial region , the bulging from aortic aneurism
and pericaidial effusion should also be borne in
mind. The deformities of the chest (q v.) may
also cause bulging, especially the apparent uni-
lateral alteration due to spinal curvature
Unilateral diminution may result from chrome
fibroid phthisis, or from old-standing pleurisy
or empyema If the fluid in the pleura! cavity
be not evacuated before changes have taken
place m the lung and pleura, the correspond-
ing side of the chest-wall becomes retracted,
secondary to a collapse of the lung Local
flattening may be noticed below the clavicle
as a result of diminished functional activity
of the upper lobes, which is usually associated
with some organic lesions of a tuberculous
nature. In children depression of the chest-
wall may follow collapse or chronic interstitial
pneumonia
Before concluding the inspection of the chest
the presence or absence of enlarged or pulsatory
blood-vessels at the base of the neck should be
observed In emphysema and chronic bronch-
itis the vessels are distended, and a pulsation
in the jugular veins is met with in cases of tn-
cuspid regurgitation Pressure on the superior
vena cava and innominate veins from aneurism
or mtrathoracic now growth produces tortuosity
of the veins above the clavicles and the engorge-
ment of the veins of the trunk and limbs
The Movements— I Lungs —In health these
are respiratory and circulatory The points to
note in regard to the respiratoiy movements
are — The rate of respiration. The average of
this is 14 to 18 per minute m the adult, in the
child more rapid, about 40 pei minute at birth,
but gradually slowing as age advances In
health the ratio between heart-beats and respira-
tory movements is 4 to 1.
Dyspnoea, or difficulty in breathing, is a com-
mon and distressing condition in chest affections.
Any cause which pi events the proper oxygena-
tion of the blood in the lungs will produce the
subjective feeling of difficulty of breathing, and
the objective signs of increased respiratory
effort The enor may bo m the respiratory
tract, sufficient oxygen not reaching the pul-
monary capillaiies, in an insufficient flow of
blood through the lungs, as in valvular disease
of the heart, in the blood itself being unable to
take up sufficient oxygen for the needs of the
body, as m advanced antenna Dyspnoea may
thus bo both inspnatoiy and expiratory It
may be for the most pait expuatoiy, as m
emphysema, \vhen the lung has lost its elastic
power, or when a tumour obstiucts the glottis
during expiration Inspiratory dyspnoea IK seen
when there is obstruction to the entrance of
air at the glottis, as in membranous laryngitis,
spasm, paralysis of the dilator muscles of the
glottis, etc. When from difficulty of breathing
the patient assumes the upright position the
condition is termed orthopncca, the position
being assumed to give the cxtraordmaiy muscles
of respuation the fullest possible play
2 The rhythm of the respiratory movements
is in health perfectly regular; in disease this
regularity may disappear A peculiar type of
irregularity, known as Cheyne-Stokes' respiration,
may be met with m advanced cardiac and renal
disease and m cerebral affections In health
the relative duration of inspiration and expira-
tion is in the ratio of 5 6 In disease this
proportion may be lost If there be an ob-
struction to the entrance of air into the chest,
inspiration will be piolongcd There is marked
prolongation of expiration \thon there is diffi-
culty m expelling the air from the chest, as in
asthma and emphysema.
3. The type of the respiratory movement differs.
i of the In to
tlw thortuiio
HIP n
Uio mitral a
j>, tte ii
f, Ui«
of ttn^imigu p,»i«*wfty,
tlse
Of tlw ftlttl ttttt
oii «it1«!f flit M»?i tlifr
of W'flei*ti«rt of the ]>!tmiw.
rontimioiiN l-l.i.-k linrs in.li.Mi.- ill.- |..'ivii.,si,,n
(iiitlilirs of I In- luii^s ami tin- pulmnimrv
li>.Min-s. Tin- .l..tt«'.l liiir> .i >lio\v Mi.- lin.-.s
• if rrHi-clidii ..I' Ihc plcniif. Tin- li;.;uiv> 1, '2,
:\ indicate the upprr, ini.l.llc. ami lou.-r luiics
of tin; ri^lit lunjf ; 1 ;i.ml ;> the upper ami lower
loliesuflh,. h-H lull-.
To fax patje 84.
1-VoMi GRAHAM UIIOWN'S M^liM-l IHwjntmis, .1th Kd.
CHEST, CLINICAL INVESTIGATION OF THE
85
in the two sexes. In the male it is abdommo-
thoracic, in the female thoraeico- abdominal
In disease these typos may be altered When
the action of the diaphragm and abdominal
muscles is interfered with, as in abdominal
tumours, ascites, pain in the abdomen, the
movements may be purely thoracic , when there
is marked pleural pain tho intercostal muscles
may be more or less fixed, and the breathing be
abdominal. Pure abdominal breathing is seen
in its fully developed form m paralysis of the
intercostal muscles Diminished local expansion
is seen when one lung, or part of a lung, bo-
comes functionless, as in pleurisy with effusion,
pneumonia, phthisis
4. The extent of the chest movement has finally
to be observed In the characteristic "alar"
and "bar i el-shaped chest," previously described,
the movements are very slight. Deficient ex-
pansion or inspiration is an important diagnostic
sign When one side of the chest moves more
markedly than tho other we may find a pneu-
monia, pleurisy, or tuberculous consolidation m
the motionless side
The Circulatory Movements — The apex teat,
a gentle pulsation visible and palpable in the
fifth interspace internal to the mammary line,
extending a single interspace vertically, laterally
about one inch, regular m rhythm, and systolic
in time, is in health tho only cardiac movement
visible m the chest In disease it may be dis-
placed from its nonnal position, the whole heart
being displaced, as in pleurisy with effusion,
when tho hcait is pushed to one or other bide ,
m aseiten or alxlommal tumoui, when it is
pushed upwards , in emphysema and mefhaatin.il
tumour, when it may bo pushed downwards
By far the most common cause of dislocation of
the apox beat is, however, to bo found m tho
heart itself Marked displacement dowmvaids
and outwards is been in hypertrophy and dila-
tation of the left ventricle, as in aortic disease ,
in hypertrophy and dilatation of tho right
ventricle tho displacement is more out \\aids,
less downwards , in pericauhal effusion theic is
an upward and slightly outward displacement
Besides the apex boat, other pulsations may bo
visible, thus in the thudt fourth, im&Jifth inter-
spaces to the left of tho sternum when there is
hypertrophy of the right ventucle, or when tho
chest-wall is thin and tho lung retracted, as in
fibroid phthisis, tho pulsation of a normal right
ventricle may bo visible. Pulsation at the
second and third right costal cat tilages may bo
seen m aneurism of the aorta In retraction
of the lung the pulsation of the conus arteriosus
of tho pulmonary artery may be visible The
observer notes then tho pulsation, its position,
extent, character, and time in the cardiac cycle,
and the presence or absence of abnormal pul-
sation
LUNGS.— Palpation of the Chest-wall. —Tho
extent of the chest movements which have been
observed under inspection should be verified by
palpation, requesting tho patient to take a deep
breath The expansion of the two apices, the
two infra-clavicular regions, the axillary regions,
and tho bases of the lung should be in turn care-
fully investigated. Areas of superficial tender-
nebs may be detected during palpation, and
should bo carefully noted The state of the
intercostal spaces should bo noted, and the
presence of various accompaniments, such as
friction fremitus, rales, etc , may also be deter-
mined. Tho vocal Jremitus, or the ability of the
thoracic viscera and chest-wall to transmit vibra-
tions produced by tho voice, must then be deter-
mined This is subject to great variation con-
sistent with health, being more marked in men
than m women and children, and is diminished
when the chest-wall is well covered with muscles
and fat Further, the vocal fremitus is greater
on the in/ht side than on the left, owing to the
telativc positions of the right and loft mam
bronchi The diseases causing a decrease of
vocal fremitus aro pleural effusion, great pleural
thickening, pneumothorai, and any condition
vshich causes occlusion of a large bronchus, such
as a tumour or copious secretion of mucus. In-
crta ^e of the vocal fremitus is met with m con-
solidation of the lung (pneumonia and tubercle)
or over a cavity surrounded by consolidated lung
or a tumour in the thorax intimately connected
with a bronchus
HKArtr —Palpation of the chest-wall will also
give information as to the position and character
of tho ( ardiac pulsation, and thus confirms what
has already been observed as to the position of
the apex beat and the presence or absence of
abnormal pulsation
Tho cardiac pulsation may bo accompanied by
a thrill — a gentle vibratile sensation which is
felt on placing the hand over the region of the
heart A thrill is produced m the same way as
a murmur from fluid waves being set up within
tho blood-stream, the resulting vibrations being
sufficiently ample to pass through the chest-wall
and be perceptible to the hand of the observer
If a thrill is present note its time in the cardiac
cycle and its position and character A thnll
piesystolic in time (the most common variety)
is usually perceptible in mitral stenosis Sys-
tolic thrills, as in mitral regurgitation or aortic
stenosis, are fairly frequent, diastolic exceed-
ingly rare
In percussion of the lungs tho observer begins
above the clavicles and passes down the chest m
the mammaiy line, laying the plexiincter finger
along the interspace or rib, and not across
Compare corresponding points of the chest-wall
on the two sides, for if this be not done, the first
degree of dulness, comparative dulness, may
easily be missed In percussing in the mam-
mary region percuss outside the mammary lino ;
internal to the mammary line on the left side,
the sound will be altered by the underlying
86
CHEST, CLINICAL INVESTIGATION OP THE
heart. When percussing posteriorly strong j
percussion must be used, except at the lower j
margins of the lungs. The patient should be
bending slightly forward with the arms sym-
metrical and the head straight, foi if the head
be not straight, differing tension of the muscles
over the apex will give rise to an alteration in
the percussion sound
The normal thoracic percussion sound got on
striking over a thick layer of healthy resonant
lung may be described as an ample percussion
sound of considerable duration, lo\v in pitch, and
of a clear tone In disease the resonance of the
sound may be increased, the sound may be
hyper-resonant Slight hyper-resonance is got
in emphysema, more rnaiked on percussing over
relaxed lung, as above a pleural effusion, or
where exudation and air-containing tissue are
intimately mixed, as in oedema, early pneumonia,
etc. Marked hyper-ret>onance is met in pneumo-
thorax, pneumopencardnim The resonance of
the sound 'may be diminished — the sound is
dull Compaiative dulness is got \vheie there
is some pleura! thickening, m early phthisis,
etc , dulness where the consolidation is tuoie
advanced, as in pneumonia , absolute dulness is
found typically in effusion into the pleura In
some cases the percussion sound may have a
special quality, as the ciack-pot sound, the am-
phoric sound, the bell sound
Auscultation — Next auscultate the lungs
Note the mspiratoiy and expnatoiy phase of
the breath sound, their relative duration, their
pitch and intensity, and the piesence or absence
of a pause between them, and thus deduce the
type of the breath sound
The noimal type of btcath wund heard all
over the lung except at the mterscapular region
is vesicular Inspiration is a gentle continuous
rushing sound, expiration a thinner, fainter
sound, which at times may not IHJ audible , in-
spiration is three times as long as, and passes
directly into, expiration In disease this "v esicu-
lar murmur becomes altered The breath
sound may be harsh, as heard in the normal
child's chest, or o>er the healthy lung when the
other is rendered functionless, as in pneumonia
or pleurisy with effusion Haish wvcular breath-
ing with prolonged expiration is heard in slight
consolidation of the lung, as in tuberculosis, the
audible part of expiration being prolonged.
Wavy, jeiky, or mteirupted vesicular breathing
may be nervous in oiigin, but it usually results
from delay in the entrance of air into the
pulmonary bronchi through catarrh giving rise
to obstruction, and when localised is to be re-
garded with suspicion. Clinically it is found in
early tuberculous infiltration, bronchitis Faint-
nets or abwnce nf the bieath nouiuh may be
present if the sound vibrations produced at the
larynx and upper part of the respiratory tract
are cut off by obstruction of a bronchus, effusion
into the pleural sac, thickening of the pleura, etc
When in disease the sound vibrations pro-
duced at the naso-pharynx, pharynx, and larynx
are not damped down by passing through
spongy air-containing lung, the sound over the
chest has the same characters as at its point
of pioduction, and, being similar to the sound
leard on listening over a bronchus, is called
tronchial Inspiration and expiration are about
equal in length, they are separated by a distinct
pause and have a blowing quality Three kinds
of bronchial breath sounds arc recognised, dis-
tinguished accoiding to then pitch High-
pitched or tubular breathing, medium-pitched
n simple bronchial , low-pitched 01 cavernous
The simple or medium-pitched \anety is heard
where the lung is a better conductor of sound,
as m consolidation in phthisis The high-pitched
\ariety, more intense and harsh in thaiacter, is
found wheie consolidation is moie complete, as
in croupous pneumonia The low -pitched or
cavernous vaiicty diffeis from the other varieties
in its pitch and in ha\mg a distinctly hollow
quality It is heaid o\ei cavities in the lung,
phthisical 01 bionchiertatic
Jitoncho-veuculai Jheathiny — The type of
bieath sound heaid in health in the mtersoapulai
region and over the manubiium steim possesses
sonic of the characters oi bronchial and some of
the characters of Mwuilar bieathmg Patho-
logically it indicates sonic slight im lease in the
conducting powci of the lung, as in eaily tubei-
culous infiltration
Amjthmic bteathiny, a raio variety, has a
hollow whistling character Like bionchial, it
may be high, medium, low pit( hcd It may be
heard ovei a pncuinothorax wheie theic is free
communication between the pi em a and a
bionchus, or over smooth-walled caMties having
free communication with a bronchus
Accmnjinntmpnt* — Having determined the
type of the bieath sounds, notice the piesence
01 absence of accompaniments If present they
may be extra-pulmonary, such as friction 1 ntra-
pulinonary accompaniments may be dry rales
or rhonchi, snoi ing, cooing, whistling, or creaking
sounds due to an alt nation in the lumen of a
bronchial tube, as in asthma or bronchitis, or
theie may be moist rales or crepitations, sounds
which comey to the ear the idea of the bursting
of small bubbles 01 the ciacklmg of hair nibbed
between the fmgcis
K\ammc next the vocal resonance, asking the
patient to repeat ninety-nine, or one, one, one
In health the sound vibrations are conducted to
the stethoscope altered by their passage down
the column of air m the respiratory tract and
through the chest-wall In disease when the
lung is consolidated, as in phthisis, pneumonia,
the sound is increased When the sound is
maikcdly increased, it is called btone/iophony.
The sound violations are diminished or lost
when there are diminished facilities for their
conduction, as when a bronchus is plugged,
i of ejirtliae dtilnew in fit* fiwiwtrtlitw with
effiwim, tt, U»<* *|*ns-ttertt : A, thf tt|»|wt
i»«rfiiii of tin? Ux*r,
Sii}«rfw*iiif AIM! tl
of ili*-* ?Iglif, awrifle.
jPVomOu.xHAM liiioWM'.s M<',<li.ad Ijit.,{n,oxixt ">tli Ed.
CHEST, CLINICAL INVESTIGATION OF THE
87
when there is thickening of the pleura, effu-
sion into the pleura, oedema of the chest-wall,
etc.
Under certain conditions the whispered voice
is well heard, as if spoken into the end of the
stethoscope This is known as whiyw iny pec-
tor iloquy (see article " Lungs (Phthisis) ")
PERCUSSION OF HEART —Turning next to the
percussion of the h&irt, two areas of d illness are
recognised the (superficial or area of absolute
dulness, the deep or area of relative dulucss
The superficial catdutc did new corresponds to
that layer of the heart which lies uncovered by
lung, having a truncated pyiamidal shape, with
its right border along the left border of the
sternum, its upper boundaiy at the fourth
costal cuitilage, its left border about the parti-
bternal line The size of the area varies with
the state of expansion of the lung Tn enlarge-
ment of the heart it is increased, in emphysema
it is diminished or absent, the over-expanded
lung occupying the ami The area of diejt
cniduic dulnett is of much greatei importance
to the clinician Using stiong percussion, pei-
cussmg fioin without inwards along the third
and fourth right interspaces, the right hnrdei of
the heait is found about t\vo inches to the light
of the mid stcinal line The left bolder is next
mapped out, pel cussing along the interspaces
fiom without im\ards, beginning outside the
mammary hue, where a clear thoracic peicussiou
sound is obtainable By maikmg in each inter-
space when the relative dulucss is mat i cached
and joining the points, the position of the left
Ixmler of the heait can be obtained In health
it is usually in the mammary line, that is about
3f inches to the left of the mid-steiual line at
the level of the fourth interspace In peicuss-
mg the deep cardiac dulness, much assistance
will be got by taking into consideration the
sense of resistance when carrying out the per-
cussion The cardiac duluess is found to be
increased in cases of dilatation and hypertrophy
and in dilatation In hypertrophy and dilata-
tion of the left side the increase in the area is
downwards and out w aids , in hypertrophy and
dilatation of the right side the increased dulness
is more in the transverse direction In effusion
into the pericardium the dulness takes the shape
of the pericardial sac, it is somewhat pear-
shaped, the stalk of the pear being upwards
It is sometimes, as m emphysema, impossible to
map out the cardiac dulness with certainty A
good deal, however, will depend upon the skill
of the observer Accurate percussion of the
heart requires much practice.
Auscultation. — Taking next the auscultation of
the heart, the different cardiac areas are listened
at in turn, beginning, as a rule, with the mitral,
and the character of the sounds is noted. Aie
the sounds healthy) If not healthy, is the
alteration quantitative 1 Are the sounds louder
or fainter than in health? or is the alteration
qualitative? Is there a murmur present?
Quantitative alterations may be various, the
first sounds may be short, sharp, and accentu-
ated, as in dilatation, it may be doubled, a
somewhat rare condition , it may be prolonged
and of grave tone, as in the hypertrophy and
dilatation of chronic kidney disease The
second sound may be loud and accentuated at
either aica, it may be faint, or it may be
doubled
Is the alteration in the sounds qualitative?
Is a murmur present ? If so, time the murmur
in the cardiac cycle — systolic, diastolic, or pre-
sygtolic (aunculo-systohc) , ascertain its point
of differential maximum intensity, its sound
chaiacter, duration, and the direction of propa-
gation
JSjiha Cat time Anas — Having auscultated
the heait, the extra cardiac areas are noticed,
the uppei pait of the sternum, the roots of the
neck, and the epigastric region
1'nfjmte the up]>er part of the sternum for
any pulsation or tin ill, and percuss to ascertain
it there is any mci eased impairment of the per-
cussion sound, as in aneurism or dilatation of
the aoita Notice the root of the netk for any
swelling, undue pulsation, and for >ciious pulsa-
tion, as ui tucuspid regurgitation The cpigas-
tuc legion may show pulsation, tumour, etc,
which may ha\e important beaimg upon the
condition of the heart
In many cases the simple clinical examination
as sketched is insufficient
Extra auscultation will frequently give valu-
able information Note the cough, its < haracter,
frequency, etc
Note the presence or absence of expectoration,
its amount, reaction, appeal ance, naked-eye and
microscopic, etc
In cases where effusion into the pleura is
suspected, 01 wheie the nature of an existing
cflusion is in doubt, it is often advisable to ex-
ploic with the needle of an exploring syringe or
aspiratoi
In caidiac eases useful mfoimation may be
got from the sphygmograph, cardiograph, sphyg-
momanometer, or sphygmometcr
The Koutgen rays have been applied to the
diagnosis of icspiratory and caidiac disease, but
so far there are a number of difficulties in their
application
Con ti oiling evidence is of much importance
in many diseases of the chest Examination of
the laiynx is of the greatest importance in cases
of early phthisis, suspected aneurism
The condition of the blood, the red corpuscles,
the leucocytes, and the haemoglobin are all of
impoitance m cardiac and respiratory disease.
Thus the presence of anosmia may account for
a cardiac murmur, which otherwise must have
been considered organic, the presence of a
leucocytosis may give confirmatory evidence of
a deep-seated patch of pneumonia
CHEST, DEFORMITIES OF
I
Ohest, Deformities of.
(L) CONGENITAL DEFORMITIES . . 88
(ii.) DEFORMITIES DUB TO ALTERATIONS IN
THE PARIBTES .... 88
(ill) DEFORMITIES DUE TO MECHANICAL
CAUSES 89
(iv.) DEFORMITIES DUB TO ABNORMAL CON-
DITIONS OF THE THORACIC GROANS . 89
IN describing deformities of the chest it is most
convenient to consider them in relation to their
causal factor. The deformity may bo tho result
of a developmental error, or it may be acquired.
If acquired, it is the result of disease of the
parietes, of the thoracic organs, or from the
effects of external mechanical causes.
(i.) CONGENITAL DEFORMITIES OK THE CHEST.
— Congenital deformities of tho chest are com-
paratively rare. Cleft sternum results from
deficient union of the visceral layers in the
embryo. If the fissure be marked, ectopia
oordis results. Defects of the lateral or posterior
thoracic wall generally arise as tho result of
amniotic adhesions, and protrusion of the lung
may then take place.
(ii.) DEFORMITIES DUE TO ALTERATIONS IN THE
PARIBTES.— -The deformities of the spinal column
produce a deformity of tho thorax, slow, pro-
gressive, and at times considerable. In scoliosi*
or lateral curvature of the spine, the curvature
of the vertebral column modifies little by little
the direction of the ribs. The curvature of the
ribs is increased on the side of the vertebral
convexity, diminished on tho side of the verte-
bral concavity, and, as a consequence, there is a
protrusion of tho chest on tho side of tho spinal
convexity and a depression on the ride of the
concavity, and on the side of the spinal con-
cavity the ribs approach each other, Mid may
even overlap. Tho horizontal outline ot the
chest assumes an ellipsoidal form with a posterior
protrusion of the ribs on the side of tho scoliotic
convexity, and a projection of tho anterior angle
of tho ribs on the opposite side. Tho half of
the thorax corresponding to tho convexity is
diminished in capacity ; tho opposite half retains
its sectional capacity, but is diminished in
vertical measurement. The shoulder on the
side of the scoliotic convexity is markedly
elevated, the scapula is thrown out behind, its
angle is elevated, and is carried out from the
middle line. In a number of cases a very com-
plicated deformity is produced as the result of
curves of compensation in the vertebral column,
but there is always a diminution in the capacity
of the thorax on the side of the scoliotic con-
vexity, and as a result of this tho action of the
heart is impeded from displacement, and in-
creased work is thrown on the right side in
carrying on the pulmonary circulation.
Kypkosis or backward arching of the spine
produces a flattening of the sides of the chest,
and an increase in the antero-posterior diameter
of the chest. The sternum becomes curved
about its middle, and there thus results an
anterior convexity or arching, more rarely an
anterior concavity of the chest. The infra-
clavicular depressions are exaggerated, the in-
ferior angles of the scapulae project from the
chest-wall in the "alar" fashion, the abdomen
frequently assumes an anomalous anterior pro-
jection.
In Pott's disease or angular curvature of the
spine the deformity varies with the position of
the spinal curve. If the curve be in the upper
dorsal region the thorax is flattened from before
backwards, the antero-posterior diameter of the
horizontal section is diminished. When the
projection is in the inferior dorsal region the
thorax is flattened transversely, tho lateral
diameter of the horizontal section is diminished,
and the outline of the section assumes a circular
form.
In osteomalacia the deformities of tho cheut
are secondary to the incurvation of the spine
and tho softening of the ribs, and in advanced
cases may be very complicated.
In osteitis dfformant the opine, more or less
ankylosed, is inclined forwards in a dorsal
lordosis. The ribs are fixed posteriorly, the
chest is flattened laterally. The respiration is
impeded, and is almost purely diaphragmatic.
In acromegaly the chest is projected forwards,
the antero-posterior diameter of the horizontal
plane is increased, the lateral aspects flattened,
and the lateral diameter diminished. Tho
anterior projection is most marked in tho
lower sternal region, and thus the sternum lies
obliquely with its anterior surface directed for-
wards and upwards. The sternum is thickened,
widened, and elongated. The anterior surface
shows a series of grooves. The aiigulus Ludovici
is very prominent, the xiphisternum is elongated
and OHsified. Tho clavicles are enlarged and
the extremities thickened. The ribs are massive,
so increased in bulk that thoir edges may be
almost in contact, obliterating the intercostal
spaces; the costal cartilages, broadened and
ossified, form a chaplot, which may pass beyond
the plane of the anterior aspect of tho sternum.
Tho spine may show a pronounced dorsal
kyphosis. The whole bony framework of the
chest is hypertrophied, and the respiration is
impeded, being abdominal in type.
In rickets the costal cartilages are abnormally
firm, while the ribs are softer than natural,
especially at their enlarged growing ends. Tho
deformity is characterised by the formation of
a groove running down the chest-wall almost
parallel to the direction of the sternum, situated
outside the junction of the rib with its cartilage,
extending down to the costal margin. There is
an increase in the antero-posterior diameter of
the sectional outline, the sternum being carried
forwards, and a diminution in the transverse
diameter. In addition to this alteration in the
CHEST, DEFORMITIES OF
outline of the chest, there us an enlargement of
the cartilaginous ends of the nbs, which results
in the beaded appearance known as the " nckety
rosary" The deformity is the icsult of the
atmospheric pressuie acting upon the softened
ribs When the diaphragm descends dining
inspiration the nckety softened ribs aie unable
to withstand the atmosphciic piessuie dining
the time the fresh biipply of air is entering the
lung The chest-wall yields at its softest part,
that is, immediately external to the enlaiged
growing ends of the libs, and a sulcus forms
down the sides of the chest, while the stcinum is
carried forwards by the unyielding costal caiti-
lagcs The rickety dcioimity may foim without
any actual impediment to the entrance of air
into the chcbt, but is accentuated if any impedi-
ment such as a bronchial catanh be superadded
to the nckctb The deformity tamg due to an
undue softness of the chest-wall, the solid organs
subjacent may modify the defoimity; thus the
In or biipports the lower chest-\\all on the right
side, while the heart may foim a promincme on
the left side
In wji n\<)omyelui a Iwat-shapwl hollow home-
times develops in the upper pait of the thorax,
the icgion below the level of the fifth rib being
normal The head is buncd between the
shoulders, and the stcinum sho\\s considerable
obliquity and the shouldeis are earned foi \\aids
There is no functional disturbance
(ill ) DEFOMMITlEb OF 1KB CHEST DUB 1O
MECHANICAL CAUSES — Any more or lew* con-
tinuous alteration in position 01 increased pies-
sure will affect the outline of the thoiax and
give rise to gi eater or less deformity Ele\atum
of one shoulder, usually the left, is met with in
clerks uho, on account of the position taken
while writing, tend to have a slight lateral
spinal curvatiuc with elevation of the shoulder
Again, in persons whobe occupation necessitates
the cat lying of heavy v» eights on one arm, the
opposite shouldei takes up a higher position,
and a blight defoimity is induced In some
trades considerable deformity may result fiom
pressure, as, for example, the well-iecogmsed
depression which occurs .it the lower cud of the
sternum in shoemakers from the pressuic of the
" labt " In the developing chest of young boys
a pi ejection of one 01 moie costal cartilages
may result from lateral compiessiou in athletic
exercises The cartilage, being soft when it is
compressed between the lib and the sternum,
bends, and an angulai projection forms. In the
female, mechanical modification maj result from
tight corsetb The lo\\er ribs are foiced in \\ards
and imprint their tiaces on the viscera, the
massed intestine presses upon the pelvic organs,
the descent of the diaphragm is limited, and
the respiration becomes thoracic in type, the
respiratory capacity of the lower pait of the
chest is diminished, and the epigastric angle is
reduced The pressure results in onteroptysis,
or else, if dislocation of the different organs be
not produced, an indelible impression remains
with an alteration in the shape of the organ
(iv ) DEFORM PLIES DUE 10 ABNORMAL CONDI-
TIONS OF IIIE THORACIC ORGANS — The fiamenork
of the chest undergoing, as it does, ccaHoless
temporal y changes in outline during the respira-
tory and circulatory movements, the shape of the
outline must laigely depend upon the condition
of the contained visceia Any alteration taking
place in the thoiacic visecia must to a gi eater or
less ex tent tell upon the paiictes The develop-
ment of the chest must be dependent upon the
development of the contained organs, and any
want of respiratory capacity will tell m the
mobt ma iked manner upon the form and out-
line of the chest While thus departing from
the normal the form may not amount to absolute
deformity, but the abnormality is of importance
to the physician as showing the existence of
past or the piobabiht} of futuie lung mischief.
Of such a type is the " alai " 01 " ptciygoid "
chest In such individuals, as the result of im-
proper sui roundmgs and edu< ation during early
life, theie is deficient lung development, or it
may be that theie is a tongemtally small lung
capacity As a consequence theie is deficient
development of the chest, it is shallow and
nanoNv, there is an increased obliquity of the
nbs \\hich results in a proportional diminution
of both the an tero- posterior and transverse
diameters, the increased obliquity of the ribs
results in a drooping and foi \\aid inclination of
the shoulders, the upper part of the scapula is
thus can led foi \\aids and the angle tilted back-
uaids from the ribs, giving the chest the
pecuhai "alai " appearance \\ hile the inci eased
obliquity of the nbs results in me lease in the
veitical length of the bony framework, the
veitical capauty of the chest is really diminished
by an mcicasc in the height of the diaphiagm
Tlie flat thest, the type of the tuberculous,
sho\\s a maiked and distinctive deformity
There is a loss in the normal anterior rounding
of the chest, theie is a diminution in the antero-
pos tenor diameter of the sectional outline in the
maiked foim, the cartilages of the tiue ribs
hcvung a diminished anteiior curve, in some
cases the steinum even being depressed In the
Hat chest, as distinguished fiom the alar, there
may be no increased obliquity of the ribs Both
alai and flat chests aic essentially deformities
the result of deficient lung capacity, which is
said by some to be congenital, but may also be
the result of deficient pulmonary development
arising from ad \ersc circumstances and sur-
roundings
The pit/eon chest is characterised by an alter-
ation of the almost circular sectional outline of
the childish chest to a triangular form There
is an increase in the antero-postcnor diameter
of the chest due essentially to a straightening of
the true ribs in front of their angles, and the
90
CHEST, DEFORMITIES OF
sternum is thus earned forwards The trans-
versely constricted chest is a very common foiin
of deformity. The chest shows a depression or
groove which, commencing at the level of the
xiphisternuin, passes outwards and downwards
till it shades away towards the mid-axillary line
The transversely constricted and pigeon defoimi-
ties have essentially the same causal factor — an
impediment to the entrance of <iir into the lung
dunng the developmental pciiod of life, while
the cheat-wall is soft and yielding Given an
affection of the respiratory tract which will
interfere with the free entrance of air, such as
enlarged tonsils, bronchitis, whooping-cough,
etc , and either defoinnty may result The ic-
spnatory obstruction causes mspnatory dyspnea
with inci eased effoits at inspiration The chest
and lung are moic easily expanded above than
below, hence when the diaphragm descends and
the ribs at the upper part of the chest are diawn
up, the lungs not expanding fully at their lonci
part, there is a tendency to foim a vacuum at
the lower part of the chest, and the atmospheric'
pressuio forces in the chest-wall and a sulcus is
thus formed The sulrus corresponds to the
upper level of the abdominal organs which
support the lower pait of the chest-Hall The
transversely constricted chest is thus developed
When the mspiratory dyspnoea has been moio
pronounced and moic persistent, the deformity
advances to the pigeon chest Foiced inspira-
tion ovei -expands the upper thorax, piotiusion
of the sternum takes place, the atmospheric
pressure forces in the lower part of the chest,
producing the transverse sulcus and a bending
kick of the \iphistermim Fiom the altered
position of the steinum the costal cartilages
become straightened in front of their angles,
and the gicatest transverse diametei of the
chest lies posterior to the normal }K)sition
The emphysematous chest is characterised by
an incieasc in all the diameters of the sectional
outline of the chest — from the ellipse the out-
line assumes a cncular form Repeated and
prolonged mspnatory efforts pioduce an over-
distension of the lung , the lung becomes
emphysematous The lungs have become too
voluminous to be accommodated within the
fixed periphene of the chest when in an ellip-
soidal form, the fixed poriphertc assume a
circular outline to give a greater contained area
for the enlarged lungs The outline of the chest
is circular, there is an increase in all the
diameters, the sternum is arched, the shoulders
aie raised, and the spine is arched , the chest is
fairly described by the epithet " barrel-shaped "
The enlargement of the chest may be confined to
the parts above the level of the xiphisternum, but
frequently the whole chest is affected, in \\hich
case the cpigastnc angle is maikedly enlarged
Unilateral alteration m the shape of the cheit
may be seen in a variety of conditions affecting
the lung or pleura
A unilateral dilatation of the chest is rarely
seen in the healthy side when disease impedes
the action of the other lung On the diseased
it is markedly apparent by measurement or
inspection in pleurisy with effusion, pnoumo-
thorax, and in cases of tumour of the lung
The intercostal spaces arc obliterated, at times,
they may even bulge Movement on the affected
side is diminished, exaggerated on the sound side.
Diminution of one side of the chest may form
a very striking deformity It may follow upon
chronic fibroid and destructive changes taking
place in one lung, or upon pleurisy with effusion
or empycma In pleurisy 01 empyema, \vhile
the fluid is present, the lung is collapsed , if
be f 010 the fluid l>e evacuated changes tike place
in the lung and pleura, preventing the expansion
of the lung when the fluid ultimately becomes
evacuated or absorbed, maiked deformity icsults.
The lung can no longer expand to fill up the
affected side, the heait passes over towards the
affected side, the opposite lung becomes emphy-
si'inatous, and the atmospheiic piessuic forces,
in the chest-wall on the affected side In such a
condition thcie is marked defoinnty and diminu-
tion on the affected side, and the heart IH displaced
to wauls it Maiked deformity of a similar
natuie may result in cmonic fibroid phthisis
Local defoinnty of the chest-wall is frequently
met Local bulging or increase may be seen in
ciicumscnbcd plcural effusions, in tumour of
the lung, m henna of the lung, in caidiac
hypei trophy, m aueuiysmal tumour
Local contractions or diminution of the chest-
wall due to intrathoiacic disease is seen in
phthisis e\cn without the foimation oi a eavitv,
though it is more maiked li a vomica be present
Chest, Injuries of.
SOFT PARTS 00
RIBH AND STERNUM 91
VISCERA 92
SURGICAL At FICTIONS o» THB CHEST-WALL
1 SOFT PARTS — Concussion and contusion of
the chest without evidence of injury to internal
organs are of frequent occurrence, and in many
cases lead to no serious results, but it must bo
borne m mind that an injury which appeared
slight at fiist may later give rise to alarming
symptoms in concussion from the buffers of a
railway caniage or the pressure of part of an
ordinary carnage on the chest-wall very little
may be observed at the time, and later extensive
haemorrhage from an injured internal organ may
lead to serious complications and death In
adults this is oftoner observed than in children,
as their chests, being more yielding, bear con-
cussions much better The shock from slight
concussions is often much greater than might
be expected, because the influence produced by
them vanes greatly both in adults and children,
and cases are on record where a slight blow on
CHEST, INJURIES OF
the chest has caused profound shock and some-
times death. It is therefore extremely important
to treat all cases of concussion and contusion of
the chest, even when slight, with the greatest
caie, avoiding prolonged examination during the
period of shock Laying the patient flat in Ixxl
with warmth judiciously applied round him,
using stimulants m small quantity and often re-
peated, with subcutaneous injections of stiyeh-
nme and ethei whore the tendency to heait
failure is great, will generally be snihtient m
ordmaiy cases of shock As very serious injuries
internally may result from blows on the chest
without any e\tcinal wound 01 any hacture of
the ntw, it is important to keep the patient at
rest for eight or ten days, by which time it may
be assumed that the dangcious penod is past
Ordinary wounds not imolvmg pciietiation
into the chest, such as cuts and stabs only
passing through skin and muscle, occur fre-
quently, and should always be ticated with the
same antiseptic precautions as wounds elsewhere
When oi small SMC, after thorough cleansing, a
simple collodion dicssing may be sufficient, but
where extensive, stitches are required and
aseptic or antiseptic diessmgs, accoidmg to the
opinion of the surgeon in charge hi lacerated
wounds and in vciy slight wounds with a large
amount of extiavasatcd blood in the tissues
special care ought to be taken m the cleansing
process, as should suppuintion take place it
spie«wls with great lapidity in the cellular tissue
of the chest In all such cases, and w here
wounds involve the muscles, it is important to
note that the fixing of the diessmgw is so
arranged that the aim is bandaged to the side,
thus securing rest to the injuiud muscles At
the end of ten days the parts aie geneially
sufficiently healed to allow the aim free of the
bandages, and passive motion is employed to
prevent stiffness
\Vouvuh involvmg both the thorax awl abdomen
are comparatively common , the vault of the
diaphiagm reaches the level of the fifth, and it
may be the fouith rib on the left side, the
pleura lines piactically the entire w.ill of the
thorax , hence a penetrating insta ument its liable
to ti averse the pleural cavity and entei the
cavity of the peritoneum The injury to the
abdominal viscera may be the more serious
clement, the organs most likely to be injuied
are the stomach, liver, spleen, and kidney
Perforation of the diaphragm on the left side
may result in one or othei of the forms of
diaphiagmatic hernia (we " Diaphragm, Surgical
Affections of ")
2 THE RIBS AND STERNUM — Contusions of
the ribs are very common, and are caused by
direct violence, producing frequently very per-
sistent pain over the site of injury. If this
pain does not yield to soothing fomentations
with belladonna or laudanum for forty -eight
hours, and thereafter the application of strips
of oidmary sticking plaster applied for a week,
a small fly blister over the site of pain is very
frequently of great service
Fractures occur generally from the fourth to-
the eighth ribs, the upper and lower ribs being
more protected , the floating ribs yield more to-
injuries, and consequently are less often broken.
The most frequent seat of fracture is usually at
one or other end of the rib, and the ribs most
frequently broken are the filth and hixth A
nb may be bioken in two places, or may simply
bo cracked The diagnosis is not always easy,
a simple fiactuie being most easily felt by
placing the hand flat on the chest and directing
the patient to tike a long breath Sometimes
placing two fingers o\ei the site of pain and
piessing one in w aids enables ciepitation to be
made out It is a good plan to examine care-
fully each rib with the fingers, in order, if
possible, to make out crepitation Sometimes
this is so difficult that it is not possible to
be absolutely ceitain as to whether the rib is
bioken 01 not, but if the patient ha* intense
pain at the end of inspiration or m turning
suddenly in bed, and if his inspiration is short
and hurried, \ve arc justified in concluding that
he has had one or moic nbs bioken liibs
«tre geneially broken by ducct violence, but a
number of cases aie on iccord where after
violent sneezing or coughing one or more ribs
ha\c given way, and in the insane simply turn-
ing in bed has been known to fracture several
nbs due to disease of the bone Fractures of
the i ibs cause serious complications, with w Inch
we will deal later on when speaking of injuiics
to the viscera The treatment of a simple
fiacturc consists in strapping the injured side
and applying a bioad bandage lound the chest,
and wheie this gnes comfoit it may be con-
tinued , in ccitain cases, however, patients are
easiei without any bandage at all The fracture
is geneially united in three weeks, and it is
unnecehsaiy to keep patients in bed in uncom-
plicated cases foi longci than a few days The
coital caittlaye* aie sometimes bioken by direct
violence, 01 a severe ciush of the chest may
lead to hcveial costal cartilages giving way, and
the same treatment is employed as for fracture
of the ribs
Dislocations of the iihs — Sepaiatiou of the
head of a rib fioni its articulation with the
spinal column is exceedingly rare, while disloca-
tion of a costal cartilage from the sternum is
veiy uncommon Cases have been mentioned
both of forwaid and backward displacement,
the forward being e.isily i educed by pressure,
the backward requiring pi ensure on the sternum
while the patient takes a deep breath
Sternum — Fractures of the sternum may be
transverse 01 oblique, and are caused either by
direct or indirect violence They occur between
the mauubnum and the gladiolus, or at the
ensiform cartilage The inanubrium is generally
92
CHEST, INJURIES OF
displaced backwards and behind the gladiolus,
and is reduced when possible by placing the
patient on the back, putting the knee between
the shoulders, and pressing the ribs and gladiolus
downwaids Sometimes it is impossible to
reduce the displacement, and unless the manu-
brium is giving rise to uncomfortable pressure
symptoms, operative interference is unnecessary
The ensiform cartilage may bo driven backwards
towards the spine by direct violence, and from
pressure on the stomach vomiting may become
so persistent that an operation to replace the
displaced cartilage becomes a necessity It is
well to bear in mind that in both fractured
ribs and sternum the intercostal and internal
mammary arteries have been injured and the
patients have died from fatal haemorrhage
Compound fractures of the ribs and sternum
are dealt with in exactly the same way as com-
pound fractures elsewhere It is sometimes
necessary to remove portions of nh in such
circumstances, and the pleural cavity is as a
rule penetrated, and therefore care must be
taken to ensure careful drainage
3. THE VISCERA — Wounds of the lung lead
to various symptoms, according to their extent,
and may be produced by simple concussion,
fractured ribs, stabs by knives, swords, and
such like weapons, or by gunbhot wounds or
any projectiles having sufficient force to peno
trate the chest-wall Hromoptysis, emphysema,
pneumothorax, hnemothorax, aie the symptoms
which occui soon after an accident, while some
days after an injury to the viscera we may
have pneumonia, abscess of the lung, bronchitis,
gangrene, or hernia of the lung
Haemoptysis to a slight extent may occur in
concussion or slight injury to the substance of
the lung by a broken rib, and is frequently
accompanied by emphysema, which consists in
the air passing into the cellular tissue thiough
the opening in the lung, and is diagnosed by
placing the hand over the chest and fooling the
crackling caused by the air m the cellular tissue.
Where the wound in the lung is extensive, as
by a sword thiunt, the emphysema may extend
over the whole bcxly, and the patient may
become unrecognisable
This condition, however, is not veiy common
The treatment of moderate emphysema consists
in strapping the chest in cases of fractuie and
dressing the wound antiseptically where it has
occurred from a stab Where, however, the
emphysema is general, free incisions must be
made into the cellular tissue to allow the air to
escape, not forgetting the importance of the
incisions on each side of the larynx, as the
preasmc in that region is so great as to threaten
suffocation, and patients have died from neglect
of this precaution
Pneumothorax — In some cases of injury to
the lung, instead of emphysema occurring, the
air rushes into the pleural cavity, compressing
the lung and giving rise to the most distressing
dyspnoea, which is relieved by passing a trocar
and canula into the pleural cavity and allowing
the air to escape, having previously of course
used antiseptic treatment for the skin After
the air has escaped a rubber tube with a flange
(to prevent its passage into the chest) is intro-
duced and antiseptic dressings applied
Hcemothotax — In many cases m addition to
air m the chest a large quantity of blood may
exist from injury to the vessels in the lung
Where blood alone is extravasated the condition
is called luemothorax , where both an and blood
are present it is called heemo-pneumothorax
Those cases are generally so senous that no
mteifcreuce is possible, and patients generally
die from the extensive hecmoirhage Venesec-
tion is recommended in cases of luemorrhage in
order to pioduce faintncss and possible arrest
of the bleeding A certain uunibei of cases
recover from arrest of hwmoirhage and absorp-
tion of the fluid The balance of surgical
experience points to the impoitancu of not
interfering unless there is evidence of enipyema
Where there is a wound into the chest with free
haemorrhage the question of opening up tho
wound, turning out the clots, looking for tho
bleeding vessel 01 vessels, and if possible secur-
ing them, must bo considered and earned out
in certain cases Sometimes the htemonhage
is so great on turning out the clots from the
chest that it is better to stuft tho cavity with
gau/e
Traumatic hernia of the lung consists m the
protrusion and often tho strangulation of a
portion of tho lung through a wound in tho
chest-wall It is usually met with in wounds
which open into the pleural cavity without in-
volving tho lung itself The wound in the
chest-wall must bo of a certain size to allow of the
protrusion of the lung, and it must conespond
in position with one of the borders of the lung
or with the corner of one of its lobes The
hernia may take place as soon as the penetrat-
ing weapon is withdrawn, or it may not take
place for many hours after the injury Violent
expiratory movements have a good deal to do
with its production, part of the air expelled
from the lung on the healthy side may bo driven
into tho partially collapsed lung on tho injured
side, so that it becomes distended and may pro-
trude at the wound If, on the othei hand, the
lung itself is wounded, and especially if one of
the bronchi has been opened into, tho air simply
escapes into the pleural cavity In the first
instance, it is easy to rot inn the protruded
portion of lung, but after a time it tends to
become strangulated, congested, cedernatous,
and irreducible, and may finally become gan-
grenous and slough away. Healing is then
quite satisfactory as a rule, the wound in the
chest-wall is closed with scar tissue, and the
lung remains firmly adherent to the panetea
CHEST, INJURIES OF
93
Bullet wounds of tlie lung, as met with in civil
practice, are usually caused by shots from a
revolver They have little penetrating power,
and rarely traverse the thorax as a whole , they
may lodge in the lung, or in the pobtenor wall
of the chest, often beneath the skin The in-
jury produced resembles that caused by any
other penetrating instrument The wound in
the skin is small, and gives exit to A little ooze
of blood The features resulting fiom injury
to the lung depend on its situation and extent ,
the outlying portions may be wounded without
any definite symptoms , penctiation of the root
of the lung or its Mcimty may icsult m pneumo-
thoiax, emphysema, hfemoptysis, tuemothoiax,
etc. The presence of the bullet, as a foreign
body in the chest, does not appear to add to
the gravity of the injury The rule is not to
be too eager to follow the course of a bullet m
the chest, unless it is easily felt or is pioducing
symptoms of irritation
'I ho large calibre and slow velocity of the
rifle bullet of former days were attended with
more extensive injury of the panetes, and were
more likely to be complicated by the carrying
in of portions of clothing, splinters of bone, etc ,
and the wound of the lung was often extensive,
lacerated, and infected With the modem rifle
and bullet theie is more, likely to be a clean
small hole right tin o ugh the chest
Wound* of the /temt and j>ei icntdium aie
usually pnxluced by pointed instiuments or by
bullets which penetiate the wall of the chest,
there tito coitain raie cases on recoid m whuh
a pointed loieign body in the oesophagus has
penetrated the heait-wall
The wound of the chest-wall is usually in the
precordial legion, and may appeal to be of vciy
little impoitance The pericardium may alone
bo wounded, probably when it is on the stiotch
between its two attachment* The wall of the
heart may be penetrated or peif orated, tho
point of the weapon may be anested m the
myocaulmm of the ventucles, or may entci one
or other of the cavities of the heart Tho
nature of the wound vanes with the instiumcnt
causing it , the puncture of a needle is icadily
filled with clot , a stab with a knife may give
rise to a wound which gapes , both ventucles
may be penetiated, tho apex ot the heait may
be cut off, a bullet may pass light thiough
two or more cavities, 01 it may lodge in one of
tho latter, 'a bullet of high velocity may so
raise the hydraulic pressure m tho cavities of
tho heait that their walls may bo extensively
ruptured
The pleura and lung arc very commonly in-
jured at the same time as tho heart, especially
the anteuor reflection of the plouia on the left
side Tho great vessels of the chest may also
be involved, eg aorta, vena cava, pulmonaiy
vessels, azygos vein, etc. A wound of the heart
may interfere with its functions in various ways ,
its action may be arrested altogether by tho
injury to its walls or to itb valves, or by the
influence of the injury on its nerve mechanism,
bo that the individual dies of syncope , accumu-
lation of blood in the pericardium (heernopen-
cardmm) is a very constant accompaniment of
wounds of the heait, it may be dexived from
one of the coionary aitenes oKfiom one of the
cavities, if it docs not escape externally from
the wound in the pericardium, it accumulates
and presses directly on the heart, so that the
latter may cease to beat, if it does escape
through the wound in the pericardium, the
patient may bleed to death
If the pleuia has albo been wounded, tho
blood may pass into the plcural cavity and re-
sult m an extreme form of htemothorax
Should the patient survive, he may become
the victim of septic complications, of which
purulent pericaiditis and pleurisy are the most
important examples
The symptoms associated with the lesions
described ate veiy variable and inconstant The
patient may present no evidences of serious
injury , he may be able to stand, or oven walk ,
more often there is a condition of syncope or
collapse, which may bo rapidly fatal, there may
be external hemorrhage sufficient to cause death
m a few minutes, 01 there may be very little or
none at all The pulse is small, lapid, iriegular,
and inteimittent , the heart bounds may bo
faint or inaudible, or they may be replaced by
murmurs of very varied character , an increase
in the area of the cardiac dulness may indicate
htcmopoiiLardiuni Dyspnoea is xeiy common,
and may culminate in asphyxia , it may depend
on the insufficiency of the puluionaiy circulation
resulting fiom the feeble and injuicd condition
of the heart, or it may be due to complications
such as hwmothorax and pncumothorax
Dclnium, convulsions, paralysis are occasion-
ally obscived , the latter one usually the result
of ceiebial embolism
The tieatment of wounds of the heait does
not differ fiom \\ounds of the chest m general.
Absolute lest is essential It may be advisable
to bleed fiom the arm If there be a portion
of needle or other pointed instrument projecting
fiom the wound in the chest, it should be ex-
tracted slowly by alternate movements of trac-
tion and lotation, bo as to favoui the clotting
of blood in the tiack made by the instiument
Should there be an accumulation of blood in
the peticatdium it mavbc advisable to evacuate
it, the use of a tiocai and can ul a foi this pur-
pose ib condemned because of its incapacity to
evacuate blood which has clotted, it does not
allow one to identify and secure the bleedmg-
pomt, and its use entails the risk of wounding
the heart or the pleuia Incision of the peri-
cardium by open operation is tho procedure
recommended , great care must be taken tiot to
open into one or other of the pleuial cavities,
CHEST, INJURIES OF
especially the left; the soft parts are reflected
in the form of a flap having itb base at the right
border of the sternum , the cartilages of the
third, fourth, and fifth leit ribs are removed
with or without a portion of the sternum The
pericardium is then exposed, and may be opened
and evacuated , any bleeding-point is seized and
ligatured , a wound in the heart-wall may be
•closed with interrupted sutures , silk is usually
preferred because it is more durable than catgut,
the sutures bhould not include the endotaidium
Having attested the honuoiihagc, the \\ound in
the pericardium is sutured, leaving a small
•opening for drainage, occupied by a stiand of
gauze Any pleura! complication is thus
dealt with before closing the external wound
Should the patient recover, he should be
prohibited from attempting any exertion for
several months, for feat of the t*cai yielding
and causing aneurysm or mptiuv of the heart-
wall
Needles have been found in the heart after
death, having gi\cn rise practically to no symp-
toms , on other occasions alarming symptoms
have arisen fiom the p issagc of a needle through
the heart In one ciu»c in which a needle was
removed a distinct bruit was audible previous
to the operation, and dibappeaied immediately
after
Chest-Wall, Affections of.
Surgical
ACUTE AUSCKSS AND CKLLUUTIS 94
COLD Ausc'KSh —TUBERCULOUS DISEASE OP
STERNUM, KIBS, AND COSTAL CAHTI-
LAGE.S 94
SYPHILITIC DISEASE OF TUB STFRNUM 94
TUMOURS 94
Medical
CUTANEOUS DISORDERS
PAIN
DISORDERS OK CIKCULAIION
EMPHYSEMA
TUMOURS
AFFECT IONS o* HIE MUSCLKS
95
95
96
96
97
97
1 ACUTE CEIJiULITM AND ABSCESS OF HIE CHK8T-
WALL — This may involve the subcutaneous
cellular tissue alone, or the deeper laycis of
tissue beneath the muscles and aponeuroses
The source of infection is not always apparent ,
the axilla and the upper extremity are regarded
a& the moie common bites of the original in-
fection The cclluhtis may bpread over the
greater part of one bide of the chest, may
spread downwards into the abdominal wall or
upwards to the shoulder and neck The pleura
and lung may become involved in the infective
process
The disease is to be treated on the same linos
as acute cellulitis in other regions, eg the neck,
limbs, pelvis.
Circumsoribal acute abscess of the chest-wall
is met with in relation to acute osteomyelitis of
the ribs, especially that form which follows upon
typhoid fever
2 COLD ABHCESS OF TUB CHEST-WALL — The
common cold abscess of the chest-wall originates
in tuberculous disease of a rib or costal cartilage
or of the pleura Less frequently they result
from tuberculous disease of the sternum or from
the extension of a spinal abscess along an inter-
costal space In relation to the ribs and costal
cartilages, the abscess may develop on their
external am face or on their pleura! aspect, or
there may be an accumulation of pus on both
aspects, communicating with each other across
the in tei costal space The channel of com-
munication is otten vciy narrow, and may
easily escape detection While commonly met
with in childhood and youth, they may, like
tuberculous abscesses elsewhere, be met w ith at
any period of life They aie usually situated
on the lateral or antero-later.il aspects of the
chest-wall The clinical features ate the same
as those of tuberculous abscess m other
situations They have been known to ex-
hibit pulsations transmitted fiom the heart
When left to themselves they usually make
then way to the skin surface, and soouei or
latei luptuic and gne me to a discharging
sinus or sinuses The most satisfactory treat-
ment is to lay the abbccbs cavity freely open ,
its walls arc then dealt with on gcueial pun-
ciples , any ICGCSH 01 channel communicating
with the cavity must be exploied, caicful
search is necessary to discovei the existence
of an abscess cavity on the pleuial aspect of
the nbs or costal cartilages, portions of the
lattui may require to be removed in order to
deal with such a cavity when it is discovei ed,
all diseased bone 01 caitilage is to bo removed
The wound is then closed \\ith sututcs, or
btufted with gauzo
3 TEH ii AH Y S\PHILIS is met with in the
sternum in the form of gumma or cold abscess,
or ot a sinus leading down to carious bone Its
clinical fea tines and treatment aie the same as
in syphilitic disease ot othei bones
4 TUMOURS OF THE CHEST- WALL may be divided
into those of the soft parts and those growing
fiom the bones
Tumours of the soft parts me lude sebaceous
cysts, angiomata, lipornata, molluscum fibrosum,
sarcoma, etc
Tumours oiiginatmg in the bones include
chondromata, ostcomata, and various forms of
sarcomata The latter may oiigmato in con-
nection with the steinum or with the nbs,
they may gi\e rise to tumours of enormous size,
they may project upon the pleural aspect and
press upon the lung, the parietal pleura is
often involved in the new growth The removal
of a malignant tumour of the chest-wall is
always a formidable operation, as it usually
CHEST-WALL, AFFECTIONS OF
95
entails the removal of a portion of the parietal
pleura in addition to several ribs, and exposure
of the lung The skin over the tumour should
be reflected in the shape of a large flap, so that
it may bo possible to hermetically close the
pleural cavitv at the end of the operation
Should the lung have collapsed during its
porfoimanco, it may be confidentlv expected
that it will re-expand and resume its func-
tions While the immediate result of even
very formidable opciations may be lemaik-
abiy successful, the patient usually succumbs
to recrudescence of the sarcoma at a later
period
Secorulnry cancer of the stetnvm and of the
ribs is common enough in the <xd\anccd stages
of cancel of the breast , it is not amenable to
burgical interference
CUTANEOUS AFFECTIOVS OK THK Ci HOT- WALL
The bkm of the chest -wall is frequently
implicated m the different cutaneous affections
It is the chest that tho physician fust examines
for the eruption of scarlet lever The lose
spots of typhoid ie-ur, while appearing fiist on
the abdomen, if nu mourns, will also be visible
on the chest, the other exanthemata showing
likewise then characteristic eruption The
maculai syphihde appears upon the chest as
an isolated blotch varying fiom the size of a
linseed to about the size of the fingei nail, the
colour ranging fiom pink to bluish red or even
a brownish tint, not disappearing tmtiiely on
pressure Scatteied thioughout the blotches
or following upon them the papulai syphihde
may bo seen somewhat elevated above the
surface, varying in size up to a pea, and of
a reddish dusky colour Heipes zoster, the
vesicular eruption found on the chest along the
distribution oi an intercostal nerve, pitynasis
in its various forms , ehloasma, and other skin
affections, will be found fully discussed under
their different sections
FAIN IN THE CIIE.ST
The descriptive localisation of pain given by
different suffeiers is frequently very misleading,
it is well, therefore, in cveiy case to a«k the
patient to place the hand on the part implicated
Pain complained of in the chest may have an
oiigm outside the thoiax and its contents, as
in Carduifyta fiom chionic gastritis or hypei-
chlondia, the pain resulting from nntation of
sensory fibics in the caidiac end of the stomach
and the lower end of the oesophagus, either by
the pioducts of fermentation and putrefaction
(acetic acid, fatty acid, lactic acid) or by the
hy pei secretion of hydrochloric acid The pain
is then localised at about the junction of the
seventh costal cartilage with the sternum, and
m the back in the left interscapular region
The pain is of a burning character, and is fre-
quently relieved by vomiting In hyitena,
especially where there is ovarian irritation,
mammary and infra-mammary pain and tender-
ness is common The patient stirmks from
the slightest touch, especially it her attention
be directed to the part, frequently, but by no
means always, if the attention be diverted, the
part can bo handled without producing pain 01
shrinking In these cases the mammary tender-
ness will IM) accompanied by pain on pressure
ovoi the ovaries, increasing at the menstrual
period, and frequently with h) pel aesthetic areas
in the spinal region Pain in the chest may
be of muscular origin Myalgia, the so-called
muucu'ai ihcuiuatisin, when attacking the inter-
costal nmscU s and f.tsci<» is usually spoken of
us- Plfmotlynin Its connection with ihcuma-
tisin is not always clear, it may tesult fi<m
stiain, farigue, cold, 01 other injury to the
muscle, and from constitutional causes The
pain may be intense , breathing deeply, cough-
ing, or manipulation of the muscle causing
maiked inn ease of the suffenng. It is usually
localised to one group oi muscles Theie may
be slight pyrexia, but tho constitutional s} mp-
toms .ire not maiked A good example of the
affection is met aftci severe coughing, when
myalgia may develop in the lowei mtei costal
spaces The pain of myalgia is frequently
lehevcd by resting the affected muscle, a fact
which the suffcrei soon discovers, assuming an
attitude which will throw the aftccted group of
miiHt les as far as possible out of action Pain
in the chest may be the result of implication
of the intercostal nerves Intetcovta? nemalffia
gi\cs a pain more or less continuous with acute
exacerbations, following tho line of the inter-
costal neive, with tender points near the spine,
the mid-axillary line, and near tho middle line
m fiont The pain may lie increased by move-
ment, deep breathing, coughing, etc , but is not,
as a Mile, so much affected by these as in other
painful chest affections Occasionally mte) coital
neuiitu may develop, there is moic or less
scveie pain along the line of the affected ueive
maiked ly aggiavated by pressuic, with possibly
othci signs of neuritis, and frequently the
furthei development of Herpes zostei A
syimuetiical pam along the coiuse of a group
ot m tei costal nerves may develop in the course
of affections of the spinal cord and niemnges
wheie there is implication of the sensory roots,
tho most typical example of the condition being
found in the so-called girdle pains of tabes
doisaliH
While pam m the chest may result fiom
affections ot tho chest-wall it is frequently a
manifestation of grave disorder of tho thoracic
organs The heart and pencardium are not
normally endowed with any great degree of
sensibility, but in disease the sensibility may
be gieatly exaggerated. In Pericarditis the
subjectixe sensory disturbances vary much
96
CHEST-WALL, AFFECTIONS OF
There may be merely a feeling of discomfort
and uneasiness in the precordial region, or the
pain may be a marked symptom. The pain is
usually in the precordial region, but may be
localised in the epigastrium. In addition to
pain there is hyperasthosia (see "Pericarditis").
In the affections of the heart, pain is an
extremely variable quantity. It may be an
aching, the protest of an overworked muscle,
the intense discomfort and distress resulting
from dyspnoea, or the fully developed attack
of angina pectoris. Tho difference is one of
degree, not of kind. The special diagnostic
features will be described in the article "Heart."
Fain of plewal origin has also to be differ-
entiated. Hero the manner of onset, site, and
character of the pain, with the physical signs,
readily suffice to distinguish it. Apart from
the pain of acute pleurisy, there may bo pain
of a dull aching character, and persisting for a
lengthened period, due to pleural thickening and
adhesions, the result of previous inflammation.
Pain from aneuryum of the aorta may result
from pressure, tho tumour implicating a sensory
nerve. Much of the pain, however, may be of
the nature of a referred sensation. The pain
from direct pressure will vary with the position
of the aneurysmal tumour and the structures
implicated.
In aortitis pain may be present in the first,
second, and third right intercostal spaces. In
mediastinal growth* pain may be severe, and is
due as in aneurysm to pressure upon sensory
nerves.
Pain in affections of the lung, such as pneu-
monia, phthisis, etc., results, as a rule, from
implication of the pleura ; a referred pain may,
however, be noticed along tho course of the
intercostal nerves. Pain in inflammatory affec-
tions of the chest-wall, mamma, etc., belongs to
the domain of surgery.
The diagnosis of intrathomcic pain depends
upon the diagnosis of the condition from which
it results; and to this end the condition of
pleura, cardiac muscle, aorta, and pericardium
must be each in turn carefully investigated
(««" Pericarditis").
DISORDERS OP TUB CIRCULATION IN THE
CHEST-WALL
Considerable distension of the veins may be
noticed hi cases where tricuspid regurgitation
is present. In obstruction to the portal cir-
culation as in cirrhosis of the liver, there is
a marked distension of the superficial veins in
the lower thoracic region along with distension
of the superficial abdominal veins; the anasto
motic branches of the inferior mammary and
epigastric veins relieving the portal system in
part, become then enlarged and visible. An
enormous enlargement of the veins of the
thoracic wall forming an intricate network of
distended vessels may be visible when there is
obstruction to the return of blood from the
chest-wall to the heart. This interference with
the circulation may result from the pressure of
a tumour (new growth or enlarged glands) on
one or all of the great venous trunks or from
thrombosis. If the superior vena cava be im-
plicated, the venous distension will be bilateral ;
if one of tho innominate subclaviau or axillary
trunks, the distension will be unilateral. Ifc
must not be forgotten, however, that in nursing
women there is usually a considerable dilatation
of the superficial thoracic veins during the period
of lactation; the same may be seen during
pregnancy and menstruation.
(Edema of t?i* Chest- Wall.— (Edema of the
chest-wall may bo present as part of a general
oedema in heart and kidney disorders. There
is then considerable rcdema of legs, thighs, back,
and passing up the posterior aspect of the chest-
wall, usually symmetrically, but possibly more
marked on one or other side, if the patient has
been lying in a lateral position. (Edema local-
ised to the chest-wall, arm, and head may be
present when there is obstruction to the venous
return, as in mediastiual tumour. A localised
oedema of some diagnostic significance may
occur in the chest-wall in purulent exudation
into the pleura. Thus the writer has seen a
localised o>deraa over tho tenth and eleventh
ribs over an encysted erapyema, the oedema
being of considerable diagnostic value in the
absence of the usual signs of effusion into the
pleura. Angio-neurotic oodeina its rare in the
chest, but may occur. (Edema of the chest is
not to be mistaken for myxoedciuatous swelling
of the skin and subcutaneous tissues with their
characteristic dry, harsh, and pale appearance,
swollen, thickened, and brawny, and not pitting
on pressure.
EMPHYSEMA OP THE CHEST- WALL
Subcutaneous emphysema of the chest-wall,
a somewhat uncommon occurrence, may result
from the passage of air into the tissues, or from
tho development of gas within the tissues. The
latter is the result of bacterial action, and does
not here concern us. The passage of air into
the tissues may occur under various conditions.
In the lung of the child interlobular emphy-
sema is a possible and by no means uncommon
accident as the result of whooping-cough or
capillary bronchitis, where the cough is frequent,
violent, and paroxysmal. When the condition
is marked, the air in the interlobular connective
tissue may pass along the connective tissue
surrounding the bronchi to the root of tho lung,
and thence diffuse into the mediastinum, neck,
trunk, and the general surface of the body. In
the adult, the lobules of the lung not being
separated by distinct intervals of connective
tissue, such an accident is impossible. In the
adult the air may enter the mediastinum and
subcutaneous tissues through a lesion of some
CHEST-WALL, AFFECTIONS OF
97
portion of the respiratory or alimentary tract.
Ulceration of the larynx, trachea, bronchi, or
wound of the pleura and lung may result in
emphysema of the chest-wall. Given the forma-
tion of a cavity in the lung, the surfaces of
the pleura having become adherent, the ulcera-
tive process may pass through the parietal
pleura, and a sudden effort of coughing produce
emphysema of the chest- wall. Thus the air
may pass directly from the respiratory tract
into tho chest-wall or by way of the mediasti-
num. From the alimentary canal the air may
pass into the mediastinum through ulcoration
of the oasophagus by a malignant growth, or into
the abdominal and chest wall from the stomach
or intestine, the viscera becoming adherent to
the abdominal wall and tho ulcerativo process
subsequently invading the connective tissue.
In emphysema the skin is pale and elevated
above its surroundings. On palpation the part
is found to be very soft and yielding, quite
unlike the brawny feeling of oodema. There is
no pitting on pressure, the indentation made at
once disappearing, and on handling the part
there is palpable and at times audible crackling.
When the air has passed by way of the
mediastinum the swelling appcarK first at the
root of the neck, passing up the neck and down
over the chest-wall, and so advancing, obliterat-
ing the normal outline. When the air under
the skin remains aseptic, absorption may take
place ; if, however, decomposition occurs, very
grave complications result. In any case the
accident is a very serious one, and, giving rise
to distressing dyspnoea, is frequently the final
development in an otherwise serious condition.
TUMOURS OF THB CHBST-WALL
These belong mainly to the domain of
surgery. There are, however, certain points
that must be borne in mind and carefully
investigated in cases of obvious localised swell-
ings or new growths. These may be summarised
as follows : —
(i.) A careful examination of the condition of
the aorta, anteriorly and posteriorly, with tho
view of eliminating aiieurysm.
(ii.) The question of a modiastinal now
growth should be considered.
(iii.) If the tumour be a new growth, is it
primary or secondary to disease of the viscera,
e.g. pleura, liver, etc.
(iv.) If there are obvious indications of the
presence of fluid, is tho condition a superficial
localised one, or has it connection with a serous
cavity.
AFFBCTIONS OF THB MUSCLES OF CHEST
Myositis, or inflammation of muscle, is rare
as a primary disease, but is more common as
the secondary result of a septic process ; thus
the inflammation may go on to suppuration.
Rheumatic myositis or myalgia is common in the
intercostal muscles and fascia. Its differential
diagnosis will be found discussed under "Chest
Pain." Trichinofis is an uncommon disease in
Great Britain, but is more common in Germany,
and affects the muscles of the chest-wall along
with the other muscles of the body. The affec-
tion is due to the presence of an embryo parasite
in the muscles (see " Trichina Spinalis "). Along
with general disturbance and alimentary symp-
toms there are intense muscular pain, swelling,
tenderness, and oedema. If the respiratory
muscles become involved, there is dyspnoea. In
atrophic conditions of tho muscles of the chest-
wall fibrillary contractions may be visible, slight
momentary contractions, visible, painless, but
perceptible to tho patient, and best brought
out by pressing the muscle or drawing the
finger across tho surface. Atrophy of the
muscles may arise from various causes. It
may be part of a general muscular atrophy in a
wasting disease, as in phthisis j it may result
from separation of the muscle from its trophic
centre, as iu neuritis; or from destruction of
tlio trophic centre in the cord, as in polio-
myelitis anterior acuta. The muscles around
the shoulder-joint may atrophy in disease of the
joint^ the atrophy being usually described as
reflex. Progressive muscular atrophies do not
as a rule affect the muscles of the thorax.
Paralytic affections of the muscles of the
chest-wall are usually the result of lesions of
the central nervous system. Partial paralysis
of the intercostal muscles may be noticed in
hemiplegia, but tho fully developed bilateral
paralysis occurs in its typical form in transverse
myelitis of the cervical region of tho cord.
There is then entire paralysis of tho inter-
coatals with loss of movement in the chest, the
respiratory movements being entirely abdominal.
In diphtheritic paralysis the intercostal muscles
and diaphragm may bo involved, rendering
respiration difficult or impossible. Local para-
lysis of individual muscles may occur, for
example the pcctoralis major, from implication
of the nerve trunk to tho muscle. Hypertrophy
of the muscles of the chest may, up to a certain
point, result from over-use, aa is seen in the
respiratory muscles in emphysema.
Cheyne-Stokes' Respiration.—
A rhythmical irregularity of tho respiration in
which there is a period of gradually increas-
ing and then gradually decreasing respiratory
activity (with an acme or maximum of forcible
inspiration and expiration), followed by a period
of apnoca or cessation of all such movements.
See ItENi'iRATiON (Cheyne-Stokes). See also BRAIN,
AFFECTIONS OK BJXDOU- VESSELS (Occlusion of
Cerebral Vessels); BRAIN, TUMOURS OF (Symptom*,
Localising); BRAIN, SURGERY (Compression);
CHEAT, CLINICAL INVESTIGATION OF (Inspection,
Respiratory Rhythm) ; HEART, MYOCARDIUM AND
ENDOCARDIUM (A/ections of Myocardium, Symp-
7
98
CHEYNE-STOKES' RESPIRATION
tomatology, Dyspnoea); LUNGS, VASCULAR Dia-
ORDEHS (Pulmonary Embolism, Clinical Features) ;
MBNINGBS OF THE CEREBRUM (Purulent Menin-
gitis, Symptoms) ; MENINGITIS, TURBROULOUS
(Symptoms)-, UREMIA (Symptom*, Respiratory
System).
Chlan Turpentine.— An oleo-resin
obtained from Pistacia Terebinthw, onco used
(with hopefulness) as a possible remedy for
cancer of the uterus.
Chlandano. See BALNEOLOGY (Italy,
Calcareous Waters).
Chfarl'sSalpinffitlft. &« FALLOPIAN
TUBES (Tumours).
* — A decussatiou or crossing,
especially that of the optic nerves. See
PHYSIOLOGY, SENHES (Vision); RETINA AND
OPTIC NERVE (Affections of Optic Nerve, Symp-
toms, etc.).
Chick -Pea. See TOXICOLOGY (Food-
Stuffs, Vegetable, Lathyrism).
Chicken. See INVALID FEEDING (Meats).
Chicken-Breast. See RICKETS (Clini-
cal Features, Ghent).
Chicken -POX. See VARICELLA. See
also INFECTION (Rides for Prevention) ; NEPHRITIS
(Etiology)-. SKIN DISEASES OP THE TROPICS
(Infective).
Ch IffffOe. — The chiggcr orPulexpenetram,
a sand-flea common in tropical Africa and China.
See SKIN DISEASES OF THE TROPICS (Caused by
animal parasites).
Chilblains. See ERYTHEMA (Erythema
pemio). See also ALCOHOL (External uses) ; GAN-
GRENE (Frost-bite) ; GOUT (Irregular, Circulatory
System) ; LUPUS ERYTHEMATOSUS (Diagnosis).
Child. See CHILDREN.
Childbed. See PUBRFERIUM.
Childbirth. ^LABOUR.
Child-Crowing. See LARYNX, LARYN-
GIBMUS STRIDULUS.
Ch I Id hood. See CHILDREN ; ADOLESCENT
INSANITY; etc.
Children. See CHILDREN, DEVELOPMENT
AND CLINICAL EXAMINATION; ANESTHESIA,
CHLOROFORM (Points in, Special Cases, Children) ;
ANESTHESIA, ETHER; ASCITES (Causation, in
Children); BLADDER, INJURIES AND DISEASES
(Calculus VesiccB, Lithotomy); DIABETES MEL-
LITUS (Etiology) ; GASTROINTESTINAL DISORDERS
OF INFANCY; MKSBNTBRIO GLANDS; NEW-BORN
INFANT; PNEUMONIA, CLINICAL (Childhood) ;
PULSE (Frequency) ; RHEUMATISM IN CHILDREN ;
SCHOOL CHILDREN, MBDICAL EXAMINATION;
SYPHILIS (in Children) ; TETANY ; TUBERCULOSIS.
Children, The Development
and Clinical Examination of.
INTRODUCTORY REMARKS .... 98
GROWTH IN WEIGHT AND LENGTH . . 98
DENTITION AND ITS RELATION TO DISEASE 99
DEVELOPMENT OF VARIOUS GLANDULAR
ORGANS 100
DEVELOPMENT OF THK SPECIAL SENSES . 100
DEVELOPMENT OF THE VOLUNTARY MOTOR
FUNCTIONS 100
DEVELOPMENT OF SPEECH . . .101
ORDER AND METHOD OF CLINICAL EXAMINA-
TION 101
THE HEAD 102
THE NECK, BACK, AND LIMBS. . . 102
THE ALIMENTARY SYSTEM —
MOUTH AND THROAT . . .102
THE ABDOMEN 103
THE F*:CES 103
THE CIRCULATORY SYSTKM . . .104
THE RESPIRATORY SYSTEM . . .104
THE URINARY SYSTEM . . . .106
THE INTEGUMENTARY SYSTEM . . .106
THE TEMPERATURE 106
THE NERVOUS SYHTEM . . . .107
THE child differs from the adult not only in his
small size, his softness, and his inability to do
things, but also, very importantly, in the fact
that, if he is healthy, he is constantly growing
in bulk, in endurance, and in all sorts of capacity.
In examining sick children, therefore, we have
not only to face the ordinary problems of clinical
medicine, but wo are also continually being met
with the question, Is the patient normal for his
age as regards growth and development? If we
cannot satisfy ourselves on this point, we are
likely to miss much that is of importance in the
case. In dealing with tho investigation of
children, therefore, wo shall begin with a short
account of such facts of growth and develop-
ment as have important clinical bearings, and
then proceed to consider the examination of the
various organs and systems.
GROWTH IN WEIGHT. — At birth the baby
weighs, on an average, about 7 Ibs. (5 to 12).
During the first two days there is a loss of from
8 to 10 oz.} resulting partly from the passage of
urine and meconium, and partly from the fact
that the child does not receive enough nourish-
ment at first to make up for the tissue waste.
On the third day a gradual increase begins, the
birth- weight being reached again about the
tenth dry of life, and after this the rise con-
tinues more or less steadily. The gain may
vary considerably on different days, but the
average daily increase is about |-1 oz. during
the first five months, and from J-J oz. during
the rest of the first year.
CHILDREN, THE DEVELO
') CLINICAL EXAMINATION OP
99
By the end of the fourth month the baby's
weight should be nearly double, and by the end
of the first year about three times, its original
figure. Dm ing the second year the child gams
from 5 to 6 Ibs., during the third, about 4J
Ibs, and during the fourth, fifth, and sixth,
about 4 Ibs a year Thus by the end of the
sixth year tho weight is about six tunes, and
at fourteen years twelve tunes, as gioat as at
birth
The advantage, from a clinical point of view
of weighing infants regularly is very gicat By
it we can gauge more simply and surely than in
any other way tho extent to which a partuuLu
diet is being assimilated If a young child is
losing weight, or even not gaining it ioi sonic
weeks, this is to be icgarded as an nnpoitaut
morbid symptom, and its cause1 seaiched foi
GROWTH i\ LKwrii-— The average length of
a new-born baby is 19^ or 20 m During the
first siv months he grows fiom '1 to 5 in , and
m the second, 3 to i in Dm ing the second
year he gams from 3 to 5 in , during the
thud, '2 to 3J , and during the fouith, 2 to .1
After this tho gain is rathei less, and amounts
to \% to 2 m every year By tho end of tho
fifth year the child IMS generally doubled his
oiiginal length
Scveie chrome dyspeptic distui banco and any
other morbid conditions which profoundly mtci-
fcie with the general health arc apt to lead to
dwarfing Rickets, it seveio during eaily
infamy, has often this effect Chiomc disease
or defect of the brain generally interferes
markedly with the giowth ot the body
DENTITION— (A) The Temjman/ Teeth — The
temporal y or milk teeth aie twenty in number
The following may bo given as the usual ages
at which they appeal —
(1) Low 01 ceutial mcisois 6 to 9 months
(2) Upper ceutial and uppei
lateral mcisoi s 8 to 11 ,,
(3) Lowei lateral incisors, and
lower and upper first
rnoLiis 12 to 15 „
(4) Lower and upper canines 18 to 24 „
(5) Lower and uppei second
molais 24 to 30 „
The teeth normally come in pairs — a tooth
on one side cutting the gum about the same
time as the corresponding one on the other
side Those m the lower jaw appear a little
earlier than tho corresponding ones above,
except in the case of the lateral incisors The
intervals between the cutting of the different
groups of teeth may vary considerably m healthy
children, but the order m which they appear
seldom varies Irregularity m their order, and
the appearance of teeth singly, instead of in
pairs, is an indication of rickets Sometimes
teething begins unusually early, and infants
may even be born with one or more teeth
through the gum Early dentition has no
special clinical significance Delayed dentition
sometimes occurs without any apparent inter-
ference with the child's health (Joneuilly,
however, it is attributable to rickets, and tins
disease should always be suspected if a thild
has no teeth at ten months.
Symptom* of Teething —In many cases no-
thing unusual is noticed in tho general condition
of the child while the teeth are appearing
tluough the gum, and there is little or no local
distui bailee Often, lion over, there arc signs
that the baby has pains m its jaw when the
teeth ire coming, and thcie may also be local-
ised inflammation of the gum and greatly
increased secretion of saliva With 01 without
tlie..o lo<al symptoms we oftin find rise of
tempt i. it me, restlessness, loss of sleep, and
irritability The appetite also may be lost, and
thcit» may be constipation or slight diarrhoea.
Often the child loses weight Less frequently
slight tempoiaiy neuroses develop, e </ there
may be a constant winking of the eyes, or a
frequently recurimg cough or rapidity of
breathing without any pulmonary disease
Some children show a tendency to ccitam
diseases lit the time of teething \\hich they do
not seem to ha\e at othei times Thus it is
not very uncommon to hud a child who with
the appeal .nice of each new set of teeth has an
attack of diariluua or biouchitis which resists
tieatment stubbornly while the teeth are m
pioccss of appearing, but which lapidly ic-
covcib (under otherw ise similar conditions) when
they are through Similaily, we sec infants
with eczema who Live a maikcd rel.ipse with
each new gioup of teeth , and often an
obstinate eiuptiou will disappear almost spon-
taneously whcnc\cr all the teeth have pierced
the gum
The pl.ue of dentition as a factor in the
causation of disease is a matter which has been
much disputed There can bo no doubt that
teething is not m itself a cause of death, and
that its influence m producing and predisposing
to disease has been enormously exaggerated
At the same time it seems equally certain that
teething, like meiibtiuation, pregnancy, and
other natural states, is often accompanied by
maikcd symptoms both local and reflex, and
like them may produce temporarily a tendency
to disease which is not picsent at other times
When symptoms due to teething cause alarm,
this is not because they are themselves such as to
threaten life, but because they arc apt to lead us
to suspect the presence of some serious disease.
Thus an attack of acute bronchitis is probably
m no respect more serious m a teething infant
than m one who is not teething, but m the
former there may be an increase in tho rapidity
of the breathing and an amount of fever
present which make the case simulate one of
pneumonia
100 CHILDREN, THE DEVELOPMENT AND CLINICAL EXAMINATION OF
The diagnosis that the symptoms m a case
are due to dentition can rarely IKJ made with
any confidence until the patient is \vcll on the
way to recovery.
Treatment — Laiicmg the gums was at one
time very largely practised Now it is not
considered advisable, except occasionally when
the gum is swollen, rod, and tense over a com-
ing tooth, and the child w suffering local pain
or showing sigiiH of reflex nervous disturbance
Under these circumstances it sometimes gives
marked relief and can do no haim
The general restlessness and irritability of
teething children may be relieved by a few
grains of antipyrm, phenacctni, or biomide
An aperient generally relieves the symptoms
greatly
(fi) The Permanent Teeth — The permanent
teeth numlxir thirty-two The order and usual
time of their appe«uance is as follows —
First molars 6 years
Incisois 7 to 8 „
Bicuspids 9 to 10 „
Canines 11 to 13 „
Second molars 12 to 15 „
Third molars (wisdom teeth) 17 to 25 „
The eruption of the permanent teeth IH not a
usual source of uritation eithei local or genet al
in childhood, but the wisdom teeth, especially
those of the lower jaw, may can be some disticss
when they appear
DEVELOPMENT OF VAKIOUS (»i AVDULAK ORGANS
—The tiahvaty (Hund* find t/ie Panrttai — Not
only is the &alrva very scanty in young babies,
but it is also deficient in diastatic power Aftci
the third or fourth month its amount and itb
functional cap.uity mueose, but it is only
towards the end of the hist year, when a
number of teeth have usually appeared, that its
amylolytic action becomes ut all fully established
The action of the pmereatic secretion on starch
is practically absent at bnth, and develops,
pan jxifwi, with that of the saliva The pan-
creatiu juice is relatively active in digesting
proteids and fats e\ en in new-bom infants
The Stomnch —At bnth the stomach has its
fundus only slightly developed, so that it has a
tubular shape and a veiy small capacity Ac-
cording to Holt, the aveiage infant's stomach
can contain at bnth only 1 \ o/, , at three months
I J o/., at six months G o/ , and <it twehc months
9o-/
The stomach plays a less impoitant part in
the pioccss of digestion dining infamy than m
latet life This is owing to the uastiic juice
being scnntiei and less powerful, and to the fact
that the btoiuach contents are not allowed to
remain very long in it The zeUtively small
proportion of hydiochlonu acid in tho gastric
juico of infants piobubly helps to account foi
their chaioeteriotic susceptibility to gastro- in-
testinal infection
The Intettme. — In infants the intestine IB
relatively long, and its muscular wall compara-
tively feebly developed This latter fact helps
to explain the greater tendency to constipation
and to flatulent distension in young children.
The Thymus — The thymus gland is a large
organ at birth, weighing about half an ounce,
and it glows until, by the end of the second
year, it weighs H to 2 oz , after that age it
gradually diminishes The area of dulness over
the manubrium steini which it causes must
not be forgotten in examining the thorax in
babies
DEVELOPMENT OP IIIE SPECIAL SENSES — Eye-
sight — Within a fow weeks of birth most infants
arc evidently pleased by a brightly coloured
object or a light By the third month the child
should show that he recognises his mother's
face, and after that he soon gets to know the
look of many things He is long, however, of
being able to distinguish coloms He may
know red and yellow in the fust twelve months,
but will not probably iccognise blue and green
until the second or third year
In testing the sight in an infant, we may try
if lie follows a lighted match or othci bright
object with his ejes, whether lie scerns to le-
cognise his mother and to see familiar objects,
such as toys or food, approaching It should
also bo noticed if his pupils contract with
light and, if he is rnoie than a few months old,
with accommodation If the point of a finger
is suddenly brought clone to the eyes of a baby
ovoi two months old who has normal sight, it
causes winking
l[?<iun<i — During the first day or two of life
all childien are deaf, but by the second week
they should be able to bcai loud noises quite
well If they show no signs of doing so, it may
be suspected that they are ei$hei deaf 01 idiotic.
Although childien arc veiy early attracted and
pleased by noises, they cannot usually dis-
tinguish even their own mother's voice when
three months old
Ta*te and \mell are both relatively well
developed within the first few days of life If
they have to bo investigated in childhood,
familiar aiticles of food generally form the best
tests
tienitbtltty to touih, temperatute, aw/ pain are
not veiy acute in eaily intancy To be satis-
factory, the examination of the vanous forms of
sens ition in infancy must be not only caiefully
made but frequently repeated
DEVELOPMENT OK THE VOLUNTAIN MOTOR
Fu NCI i ova — At birth the infant's actions are
automatic, and it is only when sonic three or
foui months have passed that he acquires the
power to execute distinctly voluntary move-
ments, such as turning towards those he is fond
of, or pushing away from him something he does
not like By noticing the age at which a child
acquires the power to execute certain move-
CHILDREN, THE DEVELOPMENT AND CLINICAL EXAMINATION OF 101
ments, wo gain information as to his muscular,
and to some extent also ab to his mental de-
velopment
If a finger is laid m an infant's palm it is
generally tightly grasped, and if the child is
over five months old it will piobably albo bo
carried towards his mouth Should the child's
fingeis show no inclination to close on an object
placed m his palm, it is a morbid sign suggest-
ing usually either paralysis or gicit mental im-
pairment
A healthy, normally developed baby ought to
be able to hold his head up when he is three or
four months old, according to the degree of his»
muscular vigour Only \\hen he is eleven or
twelve months old does ho permanently acquire
the capacity for sitting unsupported Some
children creep before they walk, as early per-
haps as the ninth month, others much later A
strong baby generally begins to try to stand by
the ninth or tenth month, and he may be able
to do bo by himself by the eleventh or twelfth
Some children can walk before the end of the
hrst year, otheis not till they are nearly eighteen
months old , fourteen or fifteen months is per-
haps the average age
Any delay in the acquisition of these ordinary
muscular actions requites investigation It
may be accounted for by the weakening in-
fluence of a recent illness, or by sonic lesion of
the bones, joints, or muscles Moie commonly,
howovei, it is found to indicate the presence
either of rickets or of mental deficiency
DFAELOPMENI- OF Sraicrii — When the infant
is t \\clvo months old lie will undei stand a gocxl
many words, ami may bo able himself to use
one or two \\ith a definite meaning During
the second year his knowledge of \vords in-
creases fast, and before the end of it he may
have begun to use short phrases The age,
however, at which noimal children learn to
speak varies very gioatly
Should a child bo unable to speak by the
time ho is throe years old, the cause of this
should be investigated If he has suffered
much from illness, the backwardness in speak-
ing may be due to this only, and \vill in that
case pass of! as he icgams strength The hear-
ing should be carefully examined, compara-
tively slight deafness may mterfcie a gicut deal
with a child's pi ogress in learning to speak
Perhaps the commonest cause of delayed speech
is intellectual deficiency , the mental condition
should, therefore, always be examined in »uch
cases (see " Aphasia," " Doafmutwm ")
ORDER AND METHOD OF CLINICAL EXAMINA-
TION — When our patients ate little children we
have, while using the ordinary methods, to
shorten our examination as far as possible so as
not to exhaust them, and also to avoid very
carefully doing anything to cause them fright
or annoyance As a general rule, while in
examining adults we proceed system ly system,
investigating m turn the alimentary, circulatory,
respiratory, and other organs, in young children
we go rather by methoih We inspect hrst as
much as wo can without touching, then we pal-
pate all over, then auscultate, and so on There
are, however, of course, many exceptions to this
rule
Before commencing the physical examination
it is always well to make a few preliminary
inquiries It is important, for example, first tc
asi eitam clearly for which of the child's ailments
medical advice is sought, and how long the ill-
ness has lasted The family history is also to
be inquired into, the health of tho parents and
othei children, the state of the mother dunng
her pregnancy, and the nature of the labour
when the child was born The previous health,
development, and feeding from birth onwards
are very important, and special inquiries must
be made as to any symptom of congenital
syphilis, and .is to the dates of occurrence of
any of the infectious diseases Full details of
the nature and order of onset of the symptoms
of tho present illness should always, if possible,
be obtained
While these inquiries are being made, the
child (who should, if possible, be seated on his
mother's or nurse's knee) has time to grow
accustomed to tho doctor's presence At the
same time the medical man, without coming too
neai, may learn much to guide him in his
further examination of the child Physiognomi-
cal diagnosis plavs a fai greater part in
infancy than it does in later life, and the
physician who is practised in this art will
always be at an advantage He must not, how-
ever, trust to it for sue h information as can
only be acquired with accuracy from the ordi-
naiy and more laborious methods of examination.
The state of development and nutiition, the
complexion and expression, and the form of
the head and other uncovered parts are to IK)
specially noticed, as well as any traces of
nckets, syphilis, or other disease Tho child's
demeanour and the attitude ho assumes are also
very significant Tho number and charactei of
the respirations should be observed, and the
nature of tho cough and of the voice in speak-
ing or crying is also worthy of notice
Then comes jxitjiationt and tho pulse is gener-
ally folt first, lest its rate should bo altered by
fright or annoyance due to tho further examina-
tion A shy child's pulse will be easiest felt
while his mother keeps his hand in hers Tho
abdomen and thorax are next palpated, without
the child's position being changed (at hrst, at
any late) Tho hand is also passed over the
chest to feel tho amount of rickety beading, if
any is present, and tho position and character
of the heart's impulse The consistence of the
muscles and the mobility of the joints should
next be examined, and tho state of tho ossifica-
tion of the cranium and possible presence of
102 CHILDREN, THE DEVELOPMENT AND CLINICAL EXAMINATION OF
enlarged glands in the neck should not be over-
looked.
Auscultation should generally bo practised
before percussion, as boing loss likely to cause
annoyance, and immediate auscultation is some-
times less resented than the use of a stetho-
scope
Then comes petcussion , and l.w»tly the mouth
and tongue have to be inspected, and the gums
and fauces seen, and, if necessary, felt This is
the part of the examination which is most likely
to make the child cry, and therofoie it is left to
the end The temjteratttie may be taken at any
time before or during the examination
THE HEAD — In examining the head we must
note its SMC, shape, and ossification, including
the condition of the fontanelle and sutures
Size — At bath tho average circuinferenco of
the infant's head is 13 to 13 j inches During
the first six months it gams about 3 inches At
tho end of the first year the ho.td measured
about 18 inches , at two yoait> old about 19 , at
hve 20 to 20 \ , and at ten years about 21
inches There are, howevei, considerable vaiia-
tions in tho size of tho normal child's head As
a geneial rule, where tho head is unusual ly
large or small from causes w Inch interfere with
the health of the brain it has also a characteristic
shape.
Muipe — In tickets the cranium is squaic and
sometimes asymmetiical , sometimes it piosents
a natifoim or bossed appearance (we "Rickets")
The hydrocephahc cranium is large and rounded ,
that of microcophalus small, with a receding
forehead and a pointed vertex
Oswjicatton — This is investigated by palpating
the anterior fontauelle, the sutiues, and the back
of the head (for cramotabcs)
The Fontanelle — The normal tontandle (t e
anterior fontanelle) is thomboid in shape with
not very thin edges, and its membrane is
stretched somewhat tensely between those, so
that its surface is about the level of the sur-
rounding bones It presents a slight pulsation
transmitted to it from the artei ics at the base
oi tho brain, and a systolic murmur is often
audible over it As tho child grows older the
fontanelle gradually diminishes in size, and it
is usually closed between the fifteenth and
eighteenth months, or at latest befoie the end
of the second year It is changed in vanous
ways m disease If there is much thinnmy of
tfu: bony edaes of the fontanelle, this indicates
rickets 01 long-continued increase of the mtra-
cramal press me
Alteration* tn the tenswn and level of the mem-
brane give valuable information as to the state
of the cranial contents. Slight increase of
tension, with bulging, indicates cerebral hyper-
cemia, active or passive, and is therefore mot
with m fevei, in whooping-cough and bronchitis,
and always temporarily when the child coughs
or cries. Great tension with maiked bulging
moans considerable increase in the contents of
the skull, and is found with hydrocephalus,
mtracranial tumour, and cerebral haemorrhage.
Abnormal depression of the membrane indicates
lowering of the vital powers It is met with in
acute diarrhoea and in other exhausting condi-
tions, which call for stimulant and supporting
treatment When an infant piesents symptoms
which lead one to suspect intiacramal disease, a
normal condition ot the foiitanollo is always a
leassunng sign
Alteration1* in the vize atid date of downy of
the fontanelle are also important Gicat delay
in closuie, so that the fontancllo is too largo
for tho age of the child, is met with in rickets,
m chronic hydrocephalus, and in cretinism
Prematmo closure is a valuable early sign of
miciocephalus
The tiutuie* — Any gaping of the sutures 01
thinning oi then bony margins has tho same
significance as enlargement of the fontanelle
THE NECK —Tho state oi the lymphatic glands
in the neck should be noted as a mattci of
routine If any are culargod, tho area ot skin
or mucous mombiane connected with these
must be (aicfully examined
Stiffness of tho neck must not be overlooked
Sometimes it is duo to inusculai iheuuiatism,
sometimes to cervu al caries It is sometimes a
symptom ot basal meningitis, 01 some othoi
intiaciamal disease
THK HACK —In addition to the chaiacteristic
cuivatuies duo to Pott's disease and tukcts, wo
have to look out tor the apparent kyphosis
which is due to paialysis ot the back muscles
f torn any cause We have also to remember
that inability to hold the back straight is a
common symptom ot idiocy Any lack of
suppleness and any tenderness on iiee move-
ment of the spine should aiouse suspicion of
tuheiculous spine-disease
THE LIMBS — The state of the circulation in
the extremities, the development of the muscles,
the confirmation of the bones, and the size and
movements of the joints have all to be examined
Pain on movement ot one 01 more limbs may be
an eatly and important sign of infantile scurvy,
01 of syphilitic cpiphvsitis, 01 may be due to a
subpeiiosteal fractuie Clubbing of the fniger-
ends may thiow considerable light on the
nature oi an obscure heart or lung case, and
the presence of tubeiculous or syphilitic disease
of a finger may help to elucidate the nature of
a brain lesion In children with any manifesta-
tion of rheumatism, careful seal eh should always
be made over the bony prominences of the limbs
ior rheumatic nodules
THE MOUTH AND THROAT— The Ltp*— The
appearance oi the lips is mainly useful as an
index of the state of the circulatory system
(antenna, cyanosis, etc )
The Tontjue — In young infants the tongue is
more 01 less coated, owing to the scantiness of
CHILDREN, THE DEVELOPMENT AND CLINICAL EXAMINATION OF 103
the saliva. In older children we often meet
with the so-called " mapped " or " geographical
tongue" This condition haw nothing to do
with syphilis, and has, indeed, little practical
importance
The Teeth — In examining the teeth we have
to note the stage of piogresh of dentition and
also any abnormalities of form such OH those
characteristic of congenital syphiliH Flattening
of the tips of the more prominent teeth in lx)th
jaws indicates that the patient grinds his teeth
The Gums — Various forms of stomatitis (</ v )
exert their most charactciistic effects on the
gums Spongmoss of the gums should always
suggest the probability of scurvy being present,
although sometimes it occurs as a merely local
condition
The Palale — In examining the hard palate in
veiy young infants we often see little yellowish
nodules in the mucous membrane near the
mesial line These are called "epithelial
ixarls," being combed of degenerated epi-
thelial cells They have no clinical significance,
and lapidly disappear
The Thioat — In feverish cases of any kind
the examination ot the tliro.it must never be
omitted In <airymg this out it is of groat
importance to ensuie, to begin with, that the
child is in such a position that, when his mouth
is opened, the light \vill at once fall on the back
of the throat It is also necessary to take pre-
cautions against |x>ssiblo stiugglmg on the pait
of the patient The handle of an ordinary
spoon forms the best tongue-depressor, being
less likely to alaim the child than any speci<il
spatula
Digital examination of the pharynx, fauces,
and miso-phaiynx is very important, especially
in young infants, m whom it is often dithcult to
get a satisfactory view of these parts It is
especially called tor w hen there is a possibility
of retrophaiyugeal abscess
THE ABDOMEN — Inywtion — In young chil-
dien the abdomen is normally more prominent
than in the adult Tins is due partly to the
relatively laigc sue ot the liver and the narrow-
ness of the thoiax, and partly to the fact that
the bowels are moie icadily distended by flatu-
lence owing to the weakness of their walls
and those of the abdomen Any dilatation of
the superficial veins and any redness about the
umbilical region must l>e noticed
Retraction or hollowing out of the alxlomen
is a very significant sign of ceicbral disease
I'aljiatton — Tenderness on palpation of the
abdomen, if at all well marked, usually indicates
the presence of peritonitis or some other form
of inflammation Enlargement of the abdominal
organs and tumours are generally easily felt,
provided the children do not resist, and a
combined rectal and abdominal examination is
especially useful. In all cases of difficulty it
is advisable to give chloroform.
Percussion — Percussion is useful in detei min-
ing the state of the stomach and bowels, and in
confirming the results of palpation It IB also
of great value in ascertaining the presence of
free fluid in the peritoneum
The Liver —The lower margin of the liver
can usually t>e mode out by palpation as well as
percussion It reaches a littje below the costal
margin in the light mamillary line Diminution
in size of the liver is \ery rare Enlargement
is common, and may be due to fatty accumula-
tion, waxy disease, cirrhosis, passive congestion,
and various other causes.
The Spleen — The spleen is best investigated
in children by palpation To examine it you
stand on the child's right side, and, placing the
right hand on the left side of the abdomen with
the first two fingeis over the left hypochondnum,
press gently inwards and upwards In some
cases where the spleen is normal in size, and
always when it is enlaiged, its rounded edge
will be felt «u» a soft and readily movable body
If the lowci edge is distinctly below the level of
the ribs the organ may be regaided as abnor-
mally laige Sometimes it extends right down
into the pelvis Enlargement of the spleen is
common, and may be due to syphilis, leuctcmia,
pseudo-leuc.emia, typhoid fever, tuberculosis,
hepatic cirrhosis, and other causes
The Xfewitntt (tlanth — Tuberculosis of the
mo&entcric glands is an extremely common con-
dition from a pathologist's point of view Hin-
ically, however, it is only occasionally that we
aie able to make suie of its presence dui ing life,
.is in many of those cases in which the glands
aie most enlarged there are other changes in
the abdominal cavity which render them difficult
of palpation
EXAMINATION OF TUB FACBH — Themecomum
which the infant passes during the first three or
four days is of a dark groenish-brown coloui, of
a \iscid semi-solid consistence, slightly acid in
reaction, and without odour It is sterile at
birth, but within a few hours micro-organisms
find their way into it through the anus After
foiu or tne days the motions cease to contain
mcconmm, and assume the characters of normal
infantile f.ec'es
Nwnuil Fceiev — In a healthy breast-fed baby
the motions are from two to four in number
daily dunng the first month 01 two, and usually
two, but sometimes only one, daily after that
They are of an orange-yellow colour, and of a
uniform semi-solid consistence Then reaction
is acid, and they have a slightly sour but not
offensive odour The stools of a hand-fed infant
are similar, so long as his food resembles breast-
milk in composition and is well digested
The motions of a healthy child may vary in
numbci, consistence, colour, reaction, and odour
according to the character of the food given
him The number of the motions is increased
and the consistence lessened by increase of
104 CHILDREN, THE DEVELOPMENT AND CLINICAL EXAMINATION OF
cream in the food, and they become fewer and
more solid if the cream is lessened or the casein
increased. The colour depends for its shade
largely on the percentage of fat, being lighter if
this is small in amount The darkening of the
faeces by bismuth and uou is to be zemembered
The reaction may become alkaline from changes
taking place in the incompletely digested pro-
teids. The addition of bocf-te.i or raw-meat
juice to the diet of a milk-fed baby causes the
faeces to acquire un offensive odour
By the end of the first dentition the motions
have assumed a brownish colour, and are usually
formed
Abnormal Faeces — The appearance, reaction,
and other characters of the motions may be
greatly changed by disease (see " Gastro-Iutes-
tinal Disorders of Infancy") When a large
amount of mucus is recognisable by the naked
eye in the motions, it generally indicates disease
of the large intestine
Pus is found in the stools in cases of ulcera-
tion of the bowel, and also in severe catarrh
Blood is passed under a great variety of con-
ditions When pure blood comes m any quantity
from a child's bowel, apart from diarrhoea cr
uloeration, it generally conies from a rectal
polypus. In young infants the presence of a
small amount of blood in the motions is often
duo to an anal fissure Copious haemorrhage
from the stomach and bowel in new-born chil-
dren (mclnma ueonatorum) is fortunately rare,
but it is comparatively common to meet with
cases of spurious melsena in which blood which
has come from the nose 01 elsewhere has been
swallowed and has been passed with the
motions
Fragments of nvmhrane are found in the
stools m dysentery and m croupous enteritis
Woims and their ova are often present, and
foreign bodies such as earth, sand, stones, etc ,
may be found in the case of children who suffer
from pica
THB CiRCULAiom Si HI KM — ThePuhe — The
following may bo given as the average fnilte-
rate in healthy clnUlieu at different ages during
sleep or perfect quiet — At birth, 140 to 120
per minute, 6 to 12 mouths, 115 to 105 per
minute , 2 to 6 yeais, 105 to 90 per minute ,
11 to 14 years, 85 to 75 per minute Mental
emotion and bodily exercise may quicken the
pulse as much as twenty or thirty beats in the
mumto , honce the great importance of counting
it when the child is undisturbed While the
pulse-rate itself is often of little significance,
its ratio to the respiration -i.itc is always
important
Irregularity of the pulse is not uncommon in
children, and is generally of little importance
If, however, the pulse is slow as well as irregular,
it is worthy of careful attention Such a con-
dition of pulse sometimes occurs after acute
illness without any serious significance, but it
is also a common early symptom of mtracranial
disease.
The Heart — The heart lies more horizontally
in infancy than in later life, consequently the
apex-beat in children under four years is gener-
ally outside the nipple in the fourth intercostal
bpace The area of the deep, as well as that of
the superficial cardiac dulness is relatively laige
m childhood The normal heart-sounds in little
children are peculiar in cot tain ways The first
bound is louder than the becond m all the areas
The pulmonary second sound over the base is
normally louder than the aortic It is not to
be regarded as accentuated unless it is found to
be constantly louder than the first sounds over
the base, when the child IB at rest Owing to
the greater conductivity of the tissues the heart-
sounds are heard more distinctly all over the
thorax in young children than in adults
When heart-murmurs are found they may be
functional in character, or due to congenital
malformation or to the result of endocarditis
Functional heart-murmurs arc very rare in young
children , those due to congenital malformations
are, of course, much commoner than in later
life. When valvular disease is present it is
always of importance to ascertain, if possible,
whether or not it is of rheumatic origin For
this purpose inquiry must be made as to former
iheumatic manifestations, and the patient ex-
amined for present signs of the disease, especially
for rheumatic nodules
RKSPIRA-IORY Si SSTKM — Inspection — Form of
the Cheit — In the noiiual infant the chest is
more cylindrical than in the adult, and its
section is consequently nioie nearly circular in
outline Its shape is readily altered by any-
thing that tends to soften the already soft chest-
wall or to interfere with the free expansion of
one or both lungs The commonest alteration
which we meet with is the deformity charac-
teristic of rickets, but wo also find various
degrees of pigeon-breast, and occasionally, as in
adults, unilateral ictraction or distension, due
to pulmonary or plemal disease or to spinal
curvature
Noticeable enlargement of the superficial veins
over the upper part of the chest is a common
symptom of enlarged bronchial glands
Movement* of the Chest — (a) Their Character
— The respiratory movements of the chest are
slight in infants, because the typo of respiration
in them is almost entirely abdominal Indraw-
ing of the epigastrium and adjacent parts on
inspiration indicates, with a noimal chest, that
sufficient air is not entering the lungs, and is
an important sign In broncho-pneumonia it
helps us to gauge the extent to which the lung
is affected, while in cioup its presence to any
marked degree is one of the mam indications
for immediate surgical assistance
If the chest is abnormally collapsible from
rickets, this symptom may be present to a con-
CHILDREN, THE DEVELOPMENT AND CLINICAL EXAMINATION OF 105
siderable degree without indicating any serious
risk.
(6) Rate of the Respiration — In young infants
the rate of breathing is very variable, and it is
difficult, therefore, to estimate it correctly At
birth the number of respirations per minute
varies from 32 to 50, arid during the first year
from 25 to 35 During the second, third, and
fourth years it is about 25 per minute It
vanes, like the pulse, with the tempeiature and
with the mental state
Generally tho important point to determine
is not merely tho rate of the breathing, but tho
ratio between that and the pulse-rate The
pulse-respiration ratio should in health bo 1 to
3£ or 4, and any great disturbance of these
proportions is of clinical significance Increased
respiration -rate with dyspnoea signifies pul-
monary disease Rapid breathing without
dyspnoea may have the same significance, or it
may arise from abdominal distension or rickety
deformity of the chebt It is also met with,
and sometimes to a marked extent, in the irri-
table states which sometimes accompany teething
and htheemia
JSxtra-auvitfttttton — Before and during the
physical examination of the child's chest it is
very important to listen carefully to his breath-
ing, his cry, and his cough
(1) The Jireathtntj — Snuff,w<i breathing may
be due to ordinary catarrh When, however,
it peisists for a long period, or occuis apart
from other catarihal symptoms, it always
suggests the piesence of syphilis
tinonng during sleep, with noisy breathing
while awake, and a nasal tone of voice, com-
monly indicate the presence of cnlaiged tonsils
or adenoids, but may be due to diphtheritic
paralysis of tho palate Noi^y breathinff with
dyspnoea, chiefly during inspiration, and a cry
which is nasal but not gencially hoaisc, is
characteristic of rctrophaiyngeal abscess
Deep HtykiHsj may mean veiy little, but it is
one of the symptoms met with in the piodiomal
stage of tubeiculous meningitis
Larynyeal ot stndulout bteathiny in young
infants is most frequently due to congenital
laryngeal stridor, but may be caused by laiyn-
gitis or enlarged bronchial glands In older
children it often indicates tho presence of true
or false cioup, or of some other form of
laryngeal obstruction such as polypi
Jironchial wheezing is often readily audible in
bronchitis of the larger tubes as well as in
asthma
(2) The Cty — From the loudness of an
infant's cry wo can gauge his strength to a
certain extent If he cries loud and long wo
may be almost sure that he has no serious acute
condition of his respiratory passages A hoarse
laryngeal ciy is generally a symptom of con-
genital syphilis in young infants
(3) The Cough— The cough is loud and
clanging at the beginning of an attack of croup,
and husky and stndulous at a later stage In
bronchitis it is often deep and harsh In
pneumonia, with accompanying pleurisy, it is
nupprest>ed and painful If a child coughs
loudly without wincing, you may be sure that
he has not got acute pleurisy A loud, noisy
cough at night and in the morning is chaiacter-
istic of a catarrhal condition of the throat with
or without dyspepsia If tho cough has a dis-
tinctly paroxysmal character, this is always
suggestive of whooping-cough, especially if it is
woise at night, and sometimes ends in vomiting.
Markedly paioxysmal coughs, however, are also
met with in empyema, in enlargement of the
bronchial glands, and in some cases of simple
bronchitis
T/te Xfwtitm — It is only when children are
between five and seven years old that they begin
to expectorate natuially lief ore that age they
swallow the sputum
Real htemoptysis is laie in childhood, In
phthisis it only OLCUIS as a late symptom It
is most frequently met with in whooping-cough.
Pm SICAL EXAMINATION OP CIIEST — Palpation.
— In examining the lungs, one of the first things
to do is to asceitam the position of the /teart'i
apex-beat If it is displaced, this throws im-
poitant light on the state of the lungs
Vocal Jremitv* is often difficult to obtain in
children, owing to the quality of the child's
voice and his unwillingness to speak loud In
infants it is often got very satisfactorily during
crying
Auscultation — Little children often hold
their bieath when you try to auscultate them
This is annoying, but at least it proves that
there is no serious lung-disease picscnt Loud
crying does not interfere \\ ith auscultation very
much The long breaths which it necessitates
make any accompaniments to the bieath-sounds
more dt-aily heard, and the pmses between the
cries usually allow time to hear the heart-
sounds during one 01 two cardiac revolutions
Whimpering and sobbing are much more tiouble-
somo
The 01 ((ith Bounds in young babies are naturally
very weak, owing to the feeble, shallow nature
of their breathing As the children grow older
they get gradually loudei, and by about the age
of six months they have acquued the peculiar
harsh charac ter known as jmerile
If on auscultating a child's thest the breath-
sounds are found to diftci in loudness on the
two sides, tho side with the wcakci breathing
is almost alwajs the abnoimal one Abnormal
weakness of the breathing is met with in the
early stages of pneumonia, in pleuritic effusion,
in collapse of the lung, and in pneuinothorax
Tubulat btenthiny is more often met with in
pleurisy with effusion in child i en than in adults,
and sometimes leads to a mistaken diagnosis of
consolidation
106 CHILDREN, THE DEVELOPMENT AND CLINICAL EXAMINATION OF
Friction is sometimes difficult to make sure
of in young babies, and we have to depend on
the catch in the breath and the evident pain
accompanying it to confirm our diagnosis. A
peculiar expiratory rhythm of the breathing is
very characteristic of childhood In this there
is a loud, long expiration followed immediately
by a short inspiration, then a pause, then the
loud expiration again, and so on The pause
occurs, therefore, after inspiration, instead of, as
normally happens, after expiration This type
of breathing is often noticed in normal children
— especially when they aro frightened It is
seen maikedly in pneumonia, and in it the ex-
pirations have frequently a grunting charactei
Vocal resonance can generally be obtained best
111 young children when they are crying
Percuswon — In children a light stroke should
always be used in percussion Thw is advisable,
not only because it is less apt to annoy the child,
but also because it is more likely to lettd to
accurate results Strong percussion ovei A
part often misleads by bringing out d til ness 01
resonance from underlying oigans
It is essential to see that the patient is vfftnq
sttaiffht Even a slight twist of the spine may
give rise to distinct differences of percimsion-
note on the two sides of the chest We must
also beware of the differences dun to abnoimal
curves of the libs Too much importance: must
not be attached to small aieas of partial d illness
in <i child's chest, but at the sauio time it m
to be loniemboml that the presence of fluid in
the pleura often causes less absolute d illness in
children than might be expected
A well-marked tm<hed-pot sound can often be
obtained in little childien who have, perfectly
normal lungs — especially \\hen they are ciying
UKIVAIU S^SIEM — In young children the
bladder is higher than in later life This must
always- be remembeicd in tipping the alxlomcu
Micturition — The infant may pass water very
soon aftoi birth, but often does not do so for
twelve or even twenty -four hours During
early infancy incontinence w the- normal con-
dition Some infants have acquired a coitain
control over their bladder by eighteen months
old, in others this comes considerably later
If, however, a child cannot letain his urine to a
considerable extent, during his waking hours,
by the time he has reached his thud year, he
may be said to suffer from incontinence
Incontinence of urine may be due in girls to a
local malformation, and in both sexes to con-
ditions of geueial debility or to various severe
organic diseases of the nervous system In the
great majority of oases, however, it is a func-
tional neurosis (see " Urination ")
Retention of vt me is much less common. It
may bo the result of extreme phimosis or of an
impacted calculus It may also be due to reflex
irritation from an anal fissure, or from thread-
w orms, or to central causes, such as meningitis.
Dysurta is not uncommonly due in infants,
as well as in older children, to acid urine. In
boys it is sometimes caused by phimosU or pre-
putial adhesions. Renal colic from the passage
of uric-acid crystals is occasionally met with.
The Urine — In infants some idea of the
colour and amount of the urine passed may be
obtained by examining the napkins , but, wheie
it is possible, a pioper specimen should bo
collected
The following table (Holt) gives the average
amounts passed at different ages —
Fust twenty-four homo
Second twenty-four hours
Three to six days
Seven days to two months
T\vo to six months
Six months to two yeais
Two to five yeais
Five to eight yeais
Eight to fouiteen yeais
0 to 2 ounces
} » 3 „
3 „ 8 „
3 „ 1» »
7 „ 16 „
8 „ liO „
16 „ 26 „
20 „ 40 „
32 „ 48 „
Allninunuiia is sometimes picsent noimally
dining the hist ten days, owing, apparently, to
the passage of urn -acid crystals In older
childten its significance is the same as in adults
All c«i8e8 of albnmnmria should be examined for
traces of recent scarlatina
Jfwmatmta is found in acute nepliiitis, dis-
eases oi the bladder, and tumour of the kidney.
It is also met with in infantile scurvy, purpma,
malaria, and \atious othei conditions
Pi/ufia occurs in cystitis and pyohtis, in both
cases usually with acid mine
Cr7ycos«»ia is larely found to any gieat degiee
in childhood
TlIB INTEGUMENTARY S\8TKM The colour of
the skin as well as its state .is to moiHtuie and
temperature must always be noted , and it
must be examined for ojclema, desquamation, and
eruptions
Cyanosis setting in dnimg an acute illness is
often of great impoitance as indicating failure
of the heart or the degree to which the lungs
are affected It is also a characteristic symptom
of vanous forms of blood-poisoning When
habitually present it generally indicates the
piesence of a congenital heart -lesion The
peculiar sallow tint of the skin in infantile
scurvy, congenital syphilis, and other cachectic
conditions, is often of great assistance in
diagnosis
Undue perspiration in young children is
usually a sign of rickets, although it also occurs
in various forms of debility and in blood-poison-
ing A cold, clammy state of the extremities
should draw attention to the state of the diges-
tion and general health
TUB TEMPERATURE — In young children it is
generally more convenient to take the tempera-
ture in the groin than in the axilla, because of
the attitude they assume in sitting and the dis-
position of their clothes In important cases
CHILDREN, THE DEVELOPMENT AND CLINICAL EXAMINATION OF 107
the rectum should be preferred The ther-
mometer should never be trusted in the mr '
in young children
The normal temperature shows greater daily
variations m infancy than in adult life, but its
average level is about the same. There is a
greater tendency for the temperaturo to vaiy
upwards and down waids on blight occasion
A subnormal temperature is characteristic of
atrophy In wasted babies, therefore, a twiu-
per iture of 98° or 99° F may denote the presence
of fever
Pyrexia is sometimes caused by emotional
excitement, and sudden rises ot temperaturo are
often due to tuvial c auger* Continuous pynma,
however, is always important A high tempera-
ture occurring between the second and fifth
day after birth, unaccompanied by other obvious
symptoms of illness, i» a sign that the infant is
not getting sufficient nourishment
THK NERVOUS SYSIKM — In investigating the
presence of nervous disease m children we ha\e
not only to examine for the usual physical signs,
but also, especially in .icute cases, to make caie-
iul inqimy ioi a histoiy oi various suggestive
symptoms
Thus we may ask if any change has been
noticed lecently m the child's disposition and
temper, whethet he has complained of pain in
the head or elsewheie, 01 has h.id photophobia
or giddiness, whethei he is in the habit of
screaming out suddenly 01 sighing heavily or
gimding his teeth , whethei ho vomits 01 is
constipated, and if he has had convulsions
In looking for physical signs wo must not
omit to notice thu physiognomy, the condition
of the fontanelle and ot the superficial cranial
\euis, and toobseive if the pulse is uregulai
The state ol the pupils, and the piesenee of
squint or nystagmus, of cemcal rigidity or
head-retra( turn, aie also nnpoitant
Defects of ordinary sensibility are less com-
mon in children than in adults Pain on move-
ment of a limb is impoitant, but is not often
due to disease of tho nervous system
In investigating any apparent loss of nmsc ular
power m a child, we have, firstly, to decide
whether it is a true paralysis resulting fiom
the pain which movement causes, horn extreme
flabbmess of the muscles, oi from some nml-
toimation, and, secondly, if a true paralysis,
whether it is due to a lesion of the brain, cord,
or peripheral stiucturos, or is a so-called func-
tional palsy such as may be met with in hysteria
or as tho result of peripheral irritation
Tremor is a rare symptom in childhood, but
choroiform or athetoid movements are commoner
than in later life
When it is important to ascertain tho con-
dition of the electrical reaction m a young child,
it is generally advisable to give an antnsthctic
Chill. — An abnormally low state of the
bodily temperature, with sniveling, etc, as in
11 fold stage of ague (see MALAUIA),, or the
w^umg of the body by exposure Uf cold, or
"catching cold" (yee PFEUJIA, DISE\HES, Aiut*>
Pleurisy, Etiology).
Chlllle Paste, tee CAPMCI FRUGTUS
Chimneys. — In the construction of a
house tho chimneys should have stiaight cir-
cular flues, separate from ouch other, and should
rise 3 feet at least above the roof , in ventila-
tion they are of the greatest use as outlets, but
ought not to act as inlets tor an (cowls help
to pi event the inlet action), then action as
outlets is duo largely to the warmth of the fire
heatin ' ihe air 1 if -low, and m part to the
aspirating .«rtinn of winds blowing across the
top In Scots law (Public Health (Scotland)
Vet, 18^7) .1 chimney (not that of a private
dwelling house) sending out smoke m such
quantity as to be injurious to health is a
11 geneial nuisan< e "
See
(JEpithehoma
Chimney-Sweep's Cancer.
Sr j«nuM AND TbHiiri P, DISEASES OF (JEjntht
oj t/ie Ncrotum)
Chin -COUgh. Hte Wiroonvu-Couuu
Ch Incline. — Chinohne or quinolinc
(C,,H7N) is an alkaloid which can be made in
vaiious ways, e (/ fiom quinine, aniline, or
glycerine, and which is closely related to ben-
zene and pyridme ,SV« Ai RALOIDS (Composition
ChlnOSOl. — A propnetary compound ot
o\y< hinohne, a jellow crystalline powder, with
antiseptic pioperties, it is stated that 15
grams of it in a pint of water make a solution
equal to 1 in 40 carbolic lotion , it belongs to
the coal-tar senes, is non- poisonous and non-
corrosiNc, if used w ith perchloi ide of mercury,
both are rendcied inert
Ch lonablepsla.— Snow -blindness (Or
Xtwi', snow, and u^Ac^m, blindness)
Chlrapsy. — Friction or nibbing with tho
hands See MA TERN AT, IMPRESSIONS
Chlretta. »V« PIIARMACOLOGI , PRE-
SCRIBING — Chirutn is the dned plant (root,
stem, leaves) tiwertia chirata, which has a very
bitter taste, and contains chiratm (C20H48016,
bitter principle) and ophelic acid , it is "a bitter,
but as it contains no tannin it may be made
up with non Its official preparations are the
In fuium Chiratn' (dose, | to 1 fl oz ), the
LHJUOI Uhnata! CWwifmttt* (dose, $ to 1 fl dr),
and the T nut in a Chmitcp (dose, £ to 1 fl dr)
For In<han Chiretta, see ANDROGRAPHW
Chiropodist.— A person who treats dis-
eases of the hands and feet, but more especially
(01 entirely) conis and bunions
108
CHLOASMA
pigmentod condition of
the akin in which yellowish or brownish patches
appear, eg m pregnancy (chloaema utennum or
gravidarum), or in tubeicle (aphthisicorum), or
from the sun's rays (C caloncum), or from the
application of blisters (C toxieum) See LUNG,
TUBERCULOSIS (Complications, Integumentary),
PREGNANCY, PHYSIOLOGY (Changes in the Shn) ,
SKIN, PARASITES (Tinea Versicolor) , SKIN, PIG-
MENTARY AFFECTIONS , SYPHILIS (Dtagnons)
Chlor-. — In various compound words chlor-
occurs, and it generally signifies that cftloniie
enters into the composition of the substance for
which the woid stands In other cases it simply
means green (e g. chlorosis) In addition to the
words sepdiately considered infra, the follow ing
may be referred to hero chlwacetamide (formed
from acetamide by substituting ehloime tor
hydrogen) , chl or acetone (formed fiom acetone
by substituting chlorine for hydrogen), chlor-
acetylene (a chlorine substitution compound of
acetylene), ddoralantipyrnie (a compound of
chloral and antipyrine, acting as a hypnotic) ,
chloraloin (a substance formed bv passing
chlorine gas through solution of aloin) , chloral-
ose (a substance formed by reaction of anhydrous
chloral and glucose, and acting as a hypnotic) ,
chlor-alum (impure chloride of aluminium, act-
ing as a disinfectant), Moiamyl, cldorandtne,
chlorbenzene, chlorcaffeme, chl or camp f LOT, thlcn-
cyanogen, chlotetone, etc etc
Chloral Hydrate. See also ANAL-
GESICS AND ANODYNES , COLOUR VISION (Ac</mre<l
Colour - Mindness) , OONA ULSIONS, INFANTILE,
DRUG ERUPTIONS (Erythemutous) , KCLAMPSIA
(Treatment), HIPNUTICH, LABOUR, PRECIPITATE
AND PROLONGED (faults in tfie Soft Passes) ,
PHARMACOLOGY , PRESCRIBING , PURPURA (Symp-
tomatic Pnrpwra, Toxic), TEMPERATURE (De-
pression) , TOMCOLOOY (Organic Poisons, Chloral
Hydrate) — Chloral Hydras consists of clear,
translucent crystals, \\ith a thaiacteristic aio-
matic odour, and a bitter, pungent taste It
liquefies on heating, and is readily soluble in
water, alcohol, ether, and certain oils A thick
oily liquid results when it is mixed with camphoi
or menthol It is given in doses of 5-20 grs
Preparation — Syrupus Chloral, each fluid drachm
containing 1 0 grs Dose — \ - 2 drs Chloral is a
pure hypnotic, causing a natural sleep, which is
not followed by any unpleasant after effects
It has no analgesic action, however, and is there-
fore of little use alone in conditions associated
with severe pain, siu-h as neuralgia Its ad-
ministration is of most value in cases of simple
sleeplessness, especially if associated with rest-
lessness and excitement , in such cases it may
with advantage be combined with bromide On
account of its depressant action it must be given
with caution to patients labouring under cardiac
or respiratory embarrassment It is a strong
irritant, and may cause vomiting unless taken
well diluted. If the patient is for any reason
unable to swallow, it may be administered by the
rectum or hypodormically. There is a strong
tendency for the formation of a chloral habit,
and its use as a regular sedative and hypnotic
in chronic diseases is therefore contia-indicated
The following are some of the diseases for which
it is lecommonded — mania, delirium tremens,
whooping-cough, convulsions, tetanus, strych-
nine poisoning, severe chorea, chorea of preg-
nancy, asthma, eclampsia, and uraemia with
nervousness and restlessness
Ch loralam ide.— A h j pnotic compound,
Chloral Jotmamide, given in doses of 15 to 40
grams, it is not official, it dissolves only
slowly and imperfectly in water, but better m
acid solutions It is said that the proprietary
preparation chlorolrom resembles a mixture of
chloialamidc and bromide of potassium See
also HEART, MYOCARDIUM, DISEASES (Treatment,
Medicinal, Sleeplessness)
Chloral Ism. —Chronic poisoning due to
the chloral habit See TOXICOLOGY
Ch lorate Of Potash. See POTASSIUM ,
PREGNANCY, INTRA- UTERINE DISEASES (Intoa-
Uterine Therapeutics) , PRESCRIBING
Ch loretone.— Chloretone (CCl^ (CH J./1
OH) is a tnthloro-denvativc of teitiary butyl
alcohol (C^Oli), obtained by slowly adding
caustic potash to equal weights of chloroform
and acetone , it is ancesthetic (like cocaine) and
antiseptic See NOSE, EXAMINATION, LOCAL
AN^STHEIICS
Chloric Ether.— Spiritus Chlmoformi,
one of the official piepaiations of chloroform,
given in doses of 5 to 20 m , or in larger doses
(20 to 40 in ) if for one admimstiatioii See
CHLOROFORM , PRESCRIBING
Chloride Of Ethyl. See ANASTUESIA,
EIIIYL CHLORIDE, TEETH (Tooth. Extraction)
Chlorides. See DIET (Mineral Constitu-
ents), URINE, PATHOLOGICAL CHANGES IN (/»-
organic Constituents, Chlorides)
Chlorinated Lime. See CHLORINE
Chlorinated Soda. See CHLORINE
Chlorine. — A greenish -yellow gas with
intensely irritating properties It is not official,
but is leprosented by —
1 Calx CMminata, bleaching -powder, con-
taining 33 per cent of available chlorine, which
it gives off on exposure to air Preparation —
Liquor Calcis Chlonnatte, a 1 m 10 solution
2 Liquor Soda Chlorinate, made by mixing
solutions of sodium carbonate and chlorinated
lime Dose — 10-20 m
CHLORINE
109
Chlorinated limo is largely employed as a
disinfectant for drains, etc , and chlorine gas was
at one time a popular disinfecting agent for
rooms after infectious disease. Weak chlorine-
containing solutions are sometimes used as
mouth washes and gargles in septic conditions
pf the mouth and throat It has also been
btrorigly recommended as an internal antiseptic
in typhoid fever
Chlorlnlsm. .See TOXICOLOGY (Non-
Jfetalhc Memento, Chlorine)
Chlorobrom. See CHLORALAMIDK
Chlorodyne. tfee
(Chlotodyne Habit) , TOXICOLOGY (Allalau?*) —
A proprietary pieparatiou, used as a hypnotic ami
anodyne, it is believed that the official Tinctma
Chloroformi et Mmyhince Coniponta has a nome-
what similar composition, the latter contains
morphine hydrochlondo dissolved in amixtuio of
chloroform, tincture of capsicum, tincture of
cannabis indica, oil of peppermint, glycerine, and
alcohol, with some dilute hydrocyanic acid added
to it aftei the morphine has been dissolved m it
Ch loroform. »SVe AN I-M-HEWA, U ENKRAL
PmwioLOGY, ANAHTHESIA, CHLOROFORM 8ee
alto ABDOMEN, CLINICAL EXAMINATION , AHPTH \IA
(Cauites) , ANALGESICS AND ANODYNES, ANTI-
SPASMODICH, CHILDREN, CLINICAL EXAMINATION
OF" (Abdomen), CONVULSIONS, [NKAMILE (Tteat-
ment) , ECLAMPSIA (T>entnu>nft Attest of Fit*),
LABOUR, MANAOEMENT OF (Ancp vtketicv) , Mou-
PHINOMANIA AND ALLIED DllUO HABITS (CMotO-
fotm, xelf-admimxttation) , OX\GEN , PHARMA-
COLOGY , PRESCRIBING , ToMCOLOGl (Oli/flUlC
Powwts, Chlmofoim) — Chlon>foini1 as an
anaesthctit, is dealt with fully elsewhere,
but it is necessary hoic to add a few pai-
ticulars regarding its pharmaceutical chai adorn
Chemically, it is trichloiomcthane (CHC13),
and is a clear, colourless liquid, with a pleasant
smell and taste. There aie foui official
preparations of it A</ua Chloiofwmi (dose,
£ to 2 fl o/ ) , Litumentum Chlotofornu ,
tiptntus Chloiofotmi or Chloiic Ether (<j v ) ,
and Tinctuia Ghlorofotmi et Aloiphiiice Com-
posita (dose, 5 to 15 m ) Chloiofotmum itseli
may bo given internally m doses of 1 to 5 in
Chloroma.-- A rare disease, in which
there is a widespread development of soft green-
coloured tumours of a lymphosarcomatous
uatuie, and associated with blood changes closely
resembling those of lymphatic leukaemia It
occurs most frequently, but not exclusively, in
children under fifteen years of ago, and is moie
common in males than m females The early
symptoms are progressive wasting, weakness,
and loss of appetite, with extreme facial pallor,
which later gives place to a waxy-yellow com-
plexion There is also a heemorrhagic tendency
as shown by the formation of numerous petechiea
and ecchymoses, and suppuration occurs readily.
Exophthalmos, an important diagnostic sign, is
almost invariable, and becomes more maiked
as the disease progresses Fain in the eyes and
temporal regions is usual m the /later atagcs.
There may be some enlargement of lymphatic
glands. Examination of the blood reveals a
progressive antenna, which may reach an ex-
treme degree , and a marked luucocytosis, due
to an enormous mciedse of lymphocytes A
few rayelocytes and nucleated red corpuscles are
also usually present The diagnosis depends on
the leiikccuiic condition of the blood, the ex-
ophthalmos, and the ^ idences of tumour forma-
tion especially affecting the bones of the skulL
The disease is always itipidly fatal Authorities
aio at variance as to the exact nature of
chloroma, but it IH now recognised that the-
turnouts belong to the class of lymphosarcomata,
with a tendency to rapid and extensive meta-
static formation, and that they oiigmate chiefly
in connection >\ ith the periosteum of the bones
of the skull and face In spite of the similarity
of the blood picture to that of lymphatic leuk-
aemia and otliei points of resemblance between
the two diseases, it IH probable that the condi-
tions are essentially diffcient. The distribution
of the tumour masses is very \vide, and they
may be found in almost every oigan of the body ,
but the biain, spinal cord, and nerves escape.
The green colouration rapidly fades when the
tumours <u c exposed jtost mot tern The nature
of the colouimg mattei has not yet been deter-
mined Some regard it as being due to small
clusters of fatty material scattered about the
substance oi the tumours, otheis to a chemical
product allitd to Inmhiome, \\hich is oxidised
on exposure to light
Chlorosis.
CAUSAIION AND PATHOLOOV 110
SYMPTOMS 111
COURSE \M> PfUMINOMh 112
DIAGNOSIS 112
TKHAlMhM 113
•SVe a/so ANIMIA, ANEMIA, PERNICIOUS,
BRAIN, A H- EC i ION OF BLOOD-VESSELS (Throm-
bow), LRUCOOVIOSIH (Leucopenia) , MENSTRUA-
TION AND ITS DISORDERS (Amenw t hapa) , SKIN,
PIGMENTARY
INIRODUCTORY — (/hlorobis or green -sickness is
a disease of the female sex, occumng usually for
the first time between the ages of fourteen and
twenty years, and having aiiccmia as its cardinal
symptom The antenna is due to defective
blood formation , it occurs spontaneously, or at
least without any cause which is universally
admitted to bo sufficient, develops rapidly as a
rule, and gives rise secondarily to a number of
other symptoms If the disease is not treated
it does not tend to recovci, but to become more
no
CHLOROSIS
severe or chronic, and even when efficiently
treated it is apt to recur. As the patient
advances m years this tendency becomes less
marked
CAUSATION AND PATUOLOGY. — (I) Predisposing
Causes. — So far as is known, chlorosis occurb
only m the female sox, and the first attack
usually falls in the years between fourteen and
twenty, very seldom earlier and seldom later
Recunences may occur at any time after the
first attack, and have been met with com-
paratively late in life The disease often runs
m families, especially in large families, and the
mothers of chlorotic giils have themselves often
been affected No other illnesses in the patents
have any special i elation to chlorosis in the
children. There tniibt bo a predisposing weak-
ness of a functional character m the blood-torm-
mg organs, but Vnchow s belief that the cause
of the disease is a general hypoplaMa of the
vascular system, and the kindred notion that it
is duo to A hypoplasw of the genital organs, aio
certainly erroneous It is impossible tli.it a
disease HO curable should depend on organic
defects so seiious
(2) Exciting Causes —Such bad hygienic con-
ditions as want oi fresh an and of light in the
rooms which patients inhabit, and such faults in
clothing its corsets .so tight as to interfere with
the proper action of the viscera, may assist in
producing the disease An impiopei amount of
work and o\oiuso is probably more important,
and more hann is done by too much fatigue
than by too little Unwisdom in the choice1 of
food 01 inability to obtain a proper quantity or
quality is even more scuous The iron of the
blood is normally regenerated from the iron oi
the food, though there is a reserve m the liver
which can bo drawn upon 111 emergency Nor-
mally the intake of iron m the food, in men
at least, just balances the output, but young
women tend to prefei other foods to the 11011-
contaming proteids of a man's diet, and their
intake of non is thus often insufficient More-
over, chlorosis is very apt to appear at the time
when girls have left school and home, and have
begun to woik They need a iullei diet, especi-
ally moio proteid food, and often cannot affoid
it, are not allowed it, or will not tako it Bad
hygienic conditions, dyspepsia, constipation,
mental depression, all lead to loss of appetite
and to a diminution in the amount of food
taken In addition to a diminished intake of
iron there is in young girls an excessive output
The blood-loss of menstruation means on each
occasion an output of non equal to that in-
gested m the food in a week, and it must re-
quire a healthy appetite and ^ igorous digestion
to make good the loss Many chlorotics have
at one time suffered from menorrhagia, though
either cease to menstruate, or do so m dimin-
ished quantity In the chlorotic years the de-
velopment of the whole body goes on rapidly,
and must throw a great strain on the blood-
forming organs, and if these are imperfectly
nourished, and exposed to loss as well, chloiosis
may well result Very little is known of the
mechanism by which the blood-forming organs
are stimulated to make good any loss, and it is
possible that this may depend to a certain ex-
tent on the internal secretion of one or more
oigans, in the female sox possibly the genital
organs A loss of this stimulation from func-
tional disturbance of the generative organs may
endanger the normal course of Hood foimation
The view that chloiosis is dependent on con-
stipation has been abandoned Constipation is
not more common nor inoio severe among chlor-
otics than among other women, and puigatives
alone will not cme the disease Nor IH there
ground for believing that an abnormal amount
of intestinal putrefaction is present to pioduce
toxins which destroy the blood or hinder its
formation The ordinary evidences in the urine
of increased intestinal decomposition are want-
ing in chloiosis, nor is theie any reason to think
that excessive blood destruction oums
(3) 2'athol(M/y — Chlorosis is not a fatal dis-
ease, and hence little or nothing is known of its
moibid anatomy Fatty degeneration of the
heait and othei visceia has been ioiind in this
as m othei anaemias, the stomach may be
dilated, and so may the heait The only change
which is chaiactcnstic is the condition of the
Mood, and the only .liberation there \vhuh is
absolutely constant is the diminution of hieiuo-
globm, not only absolutely, but also relatively
to the red corpuscles The icd corpuscles in
the cubic millimetre \ary greatly in number
In cases which arc taken into hospital they are
often diminished, though very rarely below two
millions These, of couise, are the so\crc cases
In out-patient and private* pi act ice the number
is more usually about three or four millions, and
not infrequently the numbei is normal — about
4,500,000— or above the normal But even in
the cases with a normal number of coipuscles
the htemoglobin will often be diminished to 50
per cent — a colour-index of 0 5 — while when the
coipuscles aie unusually low the haemoglobin
also sinks I have taken 313 cases, tabulated
by Thayor, Cabot, Bramwell, and Stockman,
and find tho average numboi of red coipuscles
to have boon 3,800,000, while the average per-
centage of haemoglobin was 40 3 This gives a
colour-index of 0 47
Tho blood when drawn is pale and very fluid,
but coagulates rapidly, though the fibrin is not
mci eased Blood-plates arc almost always in-
creased in number , indeed, sometimes m stained
films they seem to bo almost as numerous as the
red cells
Tho red corpuscles are small, and when stained
are pale, and show specially a much paler centre
than usual This of course corresponds with
CHLOROSIS
111
their individual poverty in haemoglobin ia
slight cases their shape is often otherwise normal,
hut m severe cases poikilocytosis may be quite
as marked as in pernicious anaemia, though the
deformed coipuscles still show the central pallor.
Nucleated red corpuscles are extremely rare, and
are only found in the severest cases Leuco-
cytosis may occur m chlorosis from any of the
causes \vhich ordinarily produce it, but in un-
complicated cases the leucocytes tend to be scanty
in number rathei than increased, and to be fewei
m the worst cases than in the milder ones The
pv.icentageof lymphocytes is typically increased
The specific graMty of the blood and the diy
residue are diminished parallel to the hemo-
globin, but the plasma is unaltered It a ease
be watched through its development and le-
covery it will be found that at first the led
corpuscles are normal in number, but they be-
come small in si/e and the h<emot>lobm is dimin-
ished Then the numbei of the coipuscles begins
to fall and poikilocytosis appeals As the case
nnpioves under tieatment the coipuscles increase
rapidly in number, but remain for a long time
small and pale, and the noimal number has been
regained long before the coipuscles attain their
noi nuil size, and before the haemoglobin reaches
the noimal
The essence of the dwease is insufficient blood
foiniation , one might indeed define it as a lassi-
tude of the Ixme nun row The demand of the
body foi tiesh eoipuscles is complied \\ith, but
the corpuscles aie small and of light \\eight, and
the oxidation proc esses in the body are thus in-
terfered with
SYMPTOMS — The fiist complaint is usually
breathless! less on exeition, then follow fatigue
and palpitation Palloi, which may be greenish
in tint, does not usually appeal till the blocxl
changes are \\ell .idvanced, and sho\\s itself hist
in the lips and coiijunctiv.w, later in the skin
The patients often, indeed, have a fresh pink and
white complexion, for the vasculai nerves are
easily excited and flushing results There is
distui banco of menstruation, usually greater the
younger the patient and the more seldom she
has menstruated before Complete or partial
amenorrhoea is the rule, menorihagia is much
less common This suppression of menstruation
is of course a curative endeavour Lcucorrhwa
is common The muscular po\ver diminishes,
though hero there are great individual differ-
ences due rathei to tempo lament and will-power
than to bodily conformation Headache is com-
mon, and in bad cases one meets also tinnitus,
temporary blindness, and deafness, giddiness,
and fainting The last is specially apt to occur
after the patient has been standing for a long
time.
The amount of alimentary disturbance varies
greatly. The stomach is sometimes dilated, and
gastric ulcer is a not infrequent complication
Some patients retain a normal appetite, and
tend to become fat; others lose their
appetite, suffer from dyspeptic symptoms, and
become thin. But even those patients who
retain their appetite are very apt to be caprici-
ous in their choice of food , meat they generally
dislike, while they have a special fondness for
acids, such as lemons and vmegir, or for such
things as chalk, starch, diy oatmeal, dry tea-
leaves, or dry sago Constipation is common
The tongue is sometimes fuired and flabby, but
more usually pale and clean. The pulse is
generally lapid, the heart may be enlarged,
usually more to the light side than the left
Coldness of the hands and feet or of the whole
body, from feebleness of the peripheral circula-
tion, is often complained of, and patients often
sufter horn "dead fingers" foi the same reason
Thrombosis of the veins, especially of the legs,
occasionally occurs, and without this theio may
in severe cases be some oedema of the ankles
It is doubtful whethei these thiomboses are due
to the incmuse in blood plates or not In the
majority of cases they seem to be orgamsmal in
origin The splenic dulncss is often enlarged,
but the organ is larety palpable The mine is
copious, pale, and of low specific giavity
The patients are often imtable, capucious, 01
obstinate The headache may be constant, or
may occur in attacks like migiame Neinalgias
of all kinds aio very common, especially mfra-
inammaiy neuralgia Optic neuritis sometimes
occurs The teinperatuio seldom rises unless
for some compile ation
Cardiac atid Vascular Aluimurs — The cnrdtae
murmut * of uncomplicated chlorosis are always
systolic in tune, and aie heard most fiequeutly
in (1) the pulmonaiy aiea, \vith the point oi
maximum intensity m the second left interspace,
close to the sternum, * e just over the pulmonary
artciy The causation of this muimur has been
much discussed It has been ascribed to mitral
legurgitation, to piessuro on the pulmonary
arteiy by the dilated left amide, to \vaterincss
of the blood, and to othei causes The view
now most commonly held is th.it it is due to a
want of tone in the walls of the arteiy, similar
to that found in the heart walls, and caused by
malnutrition, and that the muimur is produced
by the sudden propulsion of the blood into the
aiteiy, \\lnch is relatively dilated in comparison
to its onfice The same cause would account
for the muimur which is sometimes heaid in
(2) the aortic aiea, though with much loss fre-
quency S) stolic murmurs in (3) the tncuspid
area and (4) the mitral aiea arc usually hoard
along uith tho basal muruiuis, but sometimes
alone, and in cases ^vheic they are not due
simply to tho conduction of leiy loud basal
munnuis, aie more serious, for they aie found
only in scveie cases of chloiosis, and indicate
that the heart wall is so enfeebled as to allow
of sufficient dilatation to cause respectively
tricuspid or mitral regurgitation It is some-
112
CHLOROSIS
times difficult to be certain m these cases
whether the murmur is due entirely to chlorotic
dilatation or to pro existing valvular disease
The history and the blood examination generally
help us, and the result of treatment usually
removes all doubt, as chlorotic dilatation is
eminently curable
Arterial murmurs arc sometimes heard at a
distance from the heart, but not with sufficient
constancy to be characteristic The tenon «
murmurs arc heard most easily in the jugular
veins, at the loot of the neck, especially on the
right side This bruit th diable, or venous hum,
is continuous, though it differs m intensity from
various causes Its causation is usually ascribed
to the fact that, while the upper part of the
vein is free, and able to collapse if ill-filled, or
if it shares in the geneial want of tone of the
vascular system, the lower pait is kept distended
by its attachments to the cervical fascia In
the passage of the blood from a nariowei to a
wider space wo have one of the typical conditions
for the production of a murmui, which is con-
tinuous because of the continuous flow of blood
in the veins A murmur of the same character
may sometimes be heaid over the eyeball, o\ei
the occipital protuberance, and elsewheio The
venous hum, though not confined to chlorosis, is
very characteristic of it
Pulsation is often to be seen and felt in the
episternal notch, m the pulmonary area, over
the area of the light ventucle, and in the epi-
gastrium From what has been said of the
state of the heait and vessels its causation in
each case will bo evident
COURSE AND PKOGNO8IR — Cases vary veiy
much in thoir rapidity of onset In some the
disease develops in a few days, but in the groat
majority its incipient stages extend over two or
three weeks, 01 even over a much longer penod
Generally speaking, cases with an acute com-
mencement recover quickly , those with a chronic
commencement take much longer to got well
But all canon, acute 01 chronic, show a marked
tendency to recurrence This is largely to be
explained by the fact that it is very difficult to
persuade chlorotics to persevere with treatment
until they have thoroughly regained their health
They are accustomed to a condition of health
which is short of robustness, and there is often
so marked an improvement after a short course
of iron that they arc satisfied with it, and drift
out of observation I have seen patients with a
haemoglobin percentage of 50 declare themselves
quite recovered, and resent the idea of further
treatment The result is a recurrence in a short
time, and those cases often become quite chioinc,
for relapses do not yield so well to iron as
primary attacks On the other hand, patients
who will submit to treatment usually recover
completely, and aie not nearly so liable to re-
lapses as imperfectly recovered cases It is, of
course, of great importance to impress upon
patients the necessity of complete recovery, for
patients suffering from chlorosis are in a poor
condition to resist acute mtercurrent diseases ;
they are liable to the development of gastric
ulcer, and if the disease is allowed to become
chrome, though the antenna may pass off in
after years, it leaves its mark in a state of
weakened vitality, and often leads to a condition
of chronic mvahdism
DIAGNOSIS — The points on which stress
should be laid are — the sex and ago, the appar-
ently causeless development of the disease, the
history and general appearance of the patient,
the character of the antenna on examination
of the blood, especially the disproportionate
diminution of haemoglobin, and the success of
treatment with iron Difficulty may arise in
cases where one or other set of symptoms of the
disease is unusually pi eminent, the gastric and
cardiac symptoms, and those associated with the
generative organs, being most likely to causo
error, and it is of couise not unusual to find
chlorosis m patients who aie suffering from
organic heait disease, fiom tubei culosis, or
other chronic maladies From other conditions
causing aiiccmia the differential diagnosis should
IHJ mode on the following lines —
(1) Pernuwus Aiwmia (t>ee "Anaemia, Per-
nicious")— It is comparatively seldom that it
is necessary to make this diagnosis, as it is very
rarely that the aniemia in chlorosis is so grave
as to give use to the suspicion of the other
disease
(2) Leucocytfi&mia — The examination of the
blood at once removes doubt.
(3) Avwrmut from Intestinal Pat antes — The
type of aniemia is rather that of peimcious
amemia Where the blocxl examination loaves
any doubt the ftec os should be examined for the
eggs of the parasites
(4) Aiurmnt pom Malignant Disease — The
type of antenna is very oiten chlorotic in malig-
nant disease , but though, of couise, malignant
disease is not specially common in young girls
without causing definite symptoms, it may
occur, and sometimes docs give rise to difficulty.
Lcuc ocy tosis is much more common in malig-
nant disease, nucleated red corpuscles are more
common and moic numerous than m chlorosis,
and the effect of treatment usually clears up
the difficulty
(5) Titbemdow — Nothing is more common
than to find early cases of phthisis and other
forms of tuberculosis taken for chlorosis, because
the lungs, otc, havo not been examined with
sufficient care The blood examination gives
very similar results, and careful investigation
of the history, repeated examination of the
sputum, lungs, glands, etc, must be made.
The temperature is not always helpful, for early
tubercle does not always cause fevor, and in
chlorosis the temperature is sometimes raised.
In vory difficult or important cases it might be
CHLOROSIS
113
possible to make the diagnosis by the injection
of tuberculin, when reaction or its absence
would make the diagnosis easy It is to be
remembered that tubercular tumour of the brain
or meningitis may cause anamna
(6) Ntmple anipmia from had hygiene, want
of food, of sleep, of light, oi fresh air, from over-
work, etc — In these cases the hemoglobin and
led corpuscles aio moio likely to bo equally
diminished, and the blood-plasma also becomes
less albuminous , but it is only m the extreme
cases that this holds, and it is necessary to
inquire \ery carefully into the patient's history
No amount ot iron will take the place of sleep
or fresh air in treatment
(7) Kidney Diheaite — Chronic nepln itis al\N ays
causes antenna m young people, but the blood-
plasma contains a smallei amount of solids
The examination of the mine usually cleats up
the diagnosis
(8) An<rmui pom Chtonic towealetl Ihvmm-
tlkuje — This may sometimes be from piles, of
which the patient, from ignoiancc 01 modesty,
does not toll hoi doctoi, but moie often from
ulcer of the stomach or duodenum These ulceis
may give rise to no symptoms, or to none that
aio not usual in chlorosis, and the blood in the
stools is so much altered that the lay public
cannot recognise it The blood examination
gives little or uo help heie, and theio will bo
need of a veiy careful review of the whole case,
and lepeated examination ot the stools
(9) Eaily Pirynanry — This must always be
borne m mind as a possible cause of amenorrhoea
and aniomia in young girls
TREATMENT — (1) Ptophyln<tic — In iamihes
whore chlorosis has occuired m the elder sisters,
it is worth while to bo specially careful of the
health of the younger sisteis dining the years
when they are likely to bo attacked From
what has been said with regatd to the etiology
of the disease it will be evident what the ne< es-
sary measures aic — a healthy life, with sufficient
food, air, and exercise It is quite useless to
give iron before the disease develops, as it does
not pi event the onset of chlorosis, and, if the
system has become habituated to its use, it may
fail entirely to assist blood foimation \vhen it is
really needed
(2) Genet a? — Sunlight and fresh an aio of
prime importance, and too much attention
cannot bo bestowed on thorn Rest is also an
all-impel t<mt factor All seveie cases should be
sent to bed, and so should all cases of medium
intensity whose circumstances \\ill allow of it
This removes the strain on the enfeebled and
badly -nourished heart, and the symptoms of
dyspnoea, famtness, headache, and neuralgia aio
relieved almost immediately The length of
time that the patient is to lemam m bed
depends on the seventy of the case and the
success of treatment, gonoially three weeks is
a sufficiently long time, but it should bo some
VOL. II
weeks longer before she is allowed to resume
her ordinary duties In slight cases, where it
is not necessary to make the patient go to bed,
she should rest as much as possible, avoid
fatigue and excitement of all kinds, and keep
early hours
The diet should be regulated to suit each
case, of course , but regulai'ly of meal times
should bf uiMHtcd on, and the want of appetite
and disinclination foi iood can often best be
dealt with by ordering lelatively small meals at
shoiter mtenals than usual— say every three
hours The distaste for meat which almost all
chloroties evince must be ovenome, gently but
lirmly , and an oidercd quantity of it, small at
hist, but increasing, must be taken The pre-
vious diet has often consisted of bulky but m-
nutiitious loods, and these should bo replaced
by proteids, whose concentrated nourishment
can be more lapidly utilised When the patient
is thin, milk with an equal quantity of cream
added to it may be given m addition to the
meat, and \\here patients cannot take solid food
milk \\ill be given largely, but to fat patients,
and to those who ha\e a good appetite for solid
food, a large quantity of milk should not be
given Alcohol, which favours fat formation,
may be given to thin patients The popular
supeistition that claret and other red wines
"make blood" is of coin so absolutely ground-
less Cold bathing, or anything else which
withdraws heat 01 causes shock to the heart,
should be avoided Tho bowels must be care-
fully regulated, as iron has a tendency to produce
constipation, though this is often ovenated
(3) tfpectal — Iron cures chlorosis in tho gieat
majonty of cases It docs not do so by replacing
lost or diminished lion in the blood The iron-
containing proteids of tho food are quite capable
of doing tins, but rest and good food alone will
not cuic chloiosis What is neccssaiy is a very
active stimulation of the bone-marrow, and the
salts of iron ( it dilating in the blood arc the best
stimulant to the marrow The form in which
iron is to be taken is to a ccitain extent a matter
of indifference, and depends upon tho digestive
powers of the patient, our ability to give a suffi-
cient amount of iron without giving too bulky a
doso of the preparation, the experience of the
physician with similar cases, and only secondarily
on the special properties of individual iron pre-
parations All of them, organic and inorganic,
are transfoimed in the stomach into leiric chlor-
ide It was supposed that the inorganic salts
of iron were not absorbed, and as a result there
were put upon the maiket numeious prepara-
tions of non-containing nuclco-albumms and pro-
teidb, undei the names of hiemofcrium, heemol,
hromatogcn, haemoglobin, carnifcrnn, ferratm,
etc These contain iron in organic combination,
and were supposed to be more easily assimilable
than the inorganic salts. They aie all, however,
too much like food -iron, do not stimulate the
8
114
CHLOROSIS
marrow with the same rapidity or vigour as the
inorganic salts, and many of them have the
further disadvantage that they contain BO small
an amount of iron that enormous doses would
have to be taken to make up the necessary
minimum daily dose, which is from (H to 0-2
grammes of metallic iron. Of the inorganic
salts, which we now know can be absorbed, the
one which is most used is the carbonate, in the
form of Blaud's pill or capsules, or as the
aaccharated carbonate. It is not astringent,
and is generally well taken. The proto-sulphate
and the ferric salts are astringent, and cannot
usually be taken by people with irritable
stomachs, but where the digestion is good they
are often very useful. Best of all, perhaps, is
reduced iron, provided it does not contain sul-
phur as an impurity ; when it is dissolved in the
gastric juice hydrogen is evolved, and if sulphur
be present, unpleasant eructations of sulphur-
etted hydrogen result. Its small dose is an
advantage. The scale preparations are some-
times useful with dyspeptics, as they are easily
taken, but they contain a relatively small
amount of iron.
The dosage should be carefully regulated.
Blaud's pill may be taken as a standard, and of
these six a day, two after each meal, should at
first be given. After three or four days or a
week the number may be doubled, if there is no
increase of gastric disturbance, and after another
week the number may again be increased. It
is rarely necessary to give more than from 20 to
24 pills a day, but the maximum, when once
reached, should be persevered with for some
weeks, and the dose then gradually decreased
for a fortnight before leaving off altogether.
The length of time during which the iron is to
be taken varies in different cases, and should be
determined by the effect on the blood. As long
as the haemoglobin percentage improves the iron
should be continued, but if it becomes stationary
it is best to stop the iron, let the patient go
without any for from two to four weeks, and
then begin again in the same way. It is gener-
ally a mistake to let a patient go on taking
iron indefinitely, as the system becomes habitu-
ated to its use, and if a relapse occurs treatment
is not so effectual. Iron must always be given
after food; no matter what form is taken, it
must be taken regularly and without interrup-
tions, and as the dyspepsia of chlorotics is usually
due to their aneemia, iron should be given even
though the patient complains of slight dyspeptic
symptoms. It may sometimes be necessary to
give a bitter tonic, or some such remedy as bis-
muth, rhubarb, and soda before food for a few
days, while the iron is being given, and it is
often wise to begin treatment with a purge.
In cases where the iron is apparently doing
no good it is well to see that the preparation
which is being taken is really active, to see, for
instance, that the pills are soluble, or to change
the preparation. Chalybeate waters are some-
times useful in such cases, or arsenic may be
tried along with or instead of the iron. It is
most likely to be useful in cases where the
number of blood corpuscles is greatly reduced,
and it must be given at first in small doses and
gradually increased. Blood-letting has been
used as a means of treatment* and might be
tried in those very chronic cases where drugs
are not very successful. Haemorrhage is a
powerful stimulant to the marrow, and may give
the necessary fillip to blood regeneration which
can then be maintained by iron. About four
ounces of blood might be drawn.
Treatment should in all cases bo continued
until the normal haemoglobin percentage is
reached, and it must bo remembered that
patients often recover a healthy appearance
long before this result is attained.
ChlprOS. — A preparation resembling chlor-
ide of lime (bleaching-powder), used as a disin-
fectant; it contains 10 per cent of available
chlorine.
ChlorOZOne.— A yellowish liquid acting
as a bleaching agent and disinfectant; it ia
formed by passing nascent hydrogen (mixed
-ith air) into caustic soda.
Chloryl. — A mixture of methyl chloride
and ethyl chloride ; a local anaosthetic.
ChoantB. — The posterior openings of the
nares. See NOSK, EXAMINATION, etc.
ChOCOlate.— Ground cocoa, with sugar,
etc., added, and with some of the fat removed.
Like cheese, it contains much nutriment in small
compass. See DIET (Fruit, Nuts).
Choke Dam p. See TOXICOLOGY (Gaseou*
Poisons, Carbon Dioxide).
Choked DISC.— Projection of the optic
papilla above the level of the retina (as seen by
the ophthalmoscope), with extension and blurring
of its border, and increased vascularity, due to
increased intracranial pressure (cerebral tumour,
nephritis); marked " papillitis." See RBTINA
AND OPTIC NERVE (Optic Nerve, Inflammation).
Choking. See ASPHYXIA (Causes) ; MEDI-
CINE, FORENSIC (Death from Asphyxia, Suffoca-
tion) ; (ESOPHAGUS (Foreign Bodies).
mla. — The presence, in excessive
amount, of bile in the blood; jaundice. See
JAUNDICE (Pathology).
CtlOlagOfflies. — A class of medicinal
substances, including podophyllum, euonymin,
iridin, sodium salicylato, mercury (calomel),
colchicum, and most of the cathartic purgatives ;
they act either directly by increasing the secre-
tion of bile, or indirectly by stimulating the
CHOLAGOGUKS
115
action of the upper part of the small intestine,
and so carrying the hilo down below the level
of the bowel whore reabsorption occurs, such
medicines ought to be followed by a saline See
PHARMACOLOGY, and imdei names of various
drugs
ChOlanfflOStomy.—- Formation of a
gall-bladder fistula
Cholanff lOtomy. — Incision of a bile
duct (mtrahepatic) for the UMnov.il of gall-stones
CtlOlangitlS. - -Inflammation of the bile
ducts, eg due to gall -stone in the common
duct See GALL - BLADDER AND BILK DUCTS,
DISEASES (Chalet tthiaiii, Cholangitis) , LIVKK,
DISEASES (Hypettovphtc Jiiliaty Cirrhosis) ,
LIVER, DiSFAHES (IftJMlttt Tuber Cttfoil*) t LlVhll
(Tropical Ahvew, Diagnosis), PANCREAS,
DISEASES (Malignant Disease)
CtlOle-. — In compound woids cholf- (from
XoArj, bile) Higmfies relattw/ to the Me In oddi-
turn to the woids specially dealt \\ith below, the
following may bo named c/wlecthyw (discharge
of bile), chol«y<*t (the gall-bladder), t holecytff t -
taw (dilatation ot the gall-bladdoi ), efwledut httt*
(inflammation of the common bile d not 01 dwtus
cominums choledochus), choledocho^tomv (the
pioduction of a fistula of the common bile duct),
ckoleit and (tauiochohc acid), t>U
CholecystOCtomy. -The removal of
the gall-bladdci, in TV hole or in pait See GALL-
BLADDER AND BILE DUCTS, DISEASES (7TMwwj«> A of
Gall-Maddo , T> eatmcnt)
CholecystendySlS.— The excision of a
gall-stone fiom the gall-bladdei, followed by
closure (by sutuies) of the opening in the gall-
bladdei, and by the anchoring of the bladdei to
the abdominal incision, which is also closed
Cholecystenterostomy. — The
establishment of an aitilui.il communication
between the gall-bladder and the intestine (e tj
the duodenum) in the tteatment of gall-stones
in the common duct See GALL-BLADDFR AND
BiLKDucrs, DISEASES (Gholdtthiaw, Treatment,
Turnout* of the Galt-JMadtler, Treatment)
Cholecystitis. — Inflammation of the
gall - bladder See GALL - BLADDER AND BILE
DUCTS, DISEASES (Cho
CholecystOStomy.— The makmgof
pening into the gall-bladder and the bringi
f an
opening into the gall-bladder and the bringing
of it into an opening in the abdominal wall (01
intestine) and fixing it there
ChOlecystotomy.— An operation in
which the abdomen is opened and the gall-
bladder incised for the icmoval of gall-stones or
some other purpose , the incision may be closed
again, or the bladder may be fixed to the abdomi-
nal wound, establishing a fistula. See GALL-
BLADDER AND BILK DUCTS, DISEASES (Chole-
lithiasis)
CholedOChotomy.— The opening of
the abdomen and the incision of the common
bilo duct for gall-stones in that duct , then the
opening may bo closed by sutures, 01 it may bo
bi ought to the abdominal yacision and a fistula
established (choledochotfomi/), or it may be made
to open into the intestine (iholerlochenterostomy)
See GALL-BLADDER AND BILE Ducrs, DISEASES
(Cholelithiaii s, Treatment)
Cholelithiasis.— Gall-stones, the dis-
eased condition caused by their presence in the
gall-bladdei, in the cystic duct, or in the
common duct See GALL-BLADDER AND BILE
DLCTS, DISEASKS (Cholelithiasis)
Cholera, Asiatic. See CUOLKRV, EPI-
DEMIC
Cholera, Epidemic.
HlNON^MS 115
BACTERIOLOGY 115
EuoLnbi 117
MOHKID ANATOMY 120
SYMPIOMS 120
PROPHYLAXIS 122
PROGNOSIS 124
TREATMENT 124
See a/w AIR, EXAMINATION (Ground Air) ,
EPIDEMIOLOGY , FACES (in certain Diseases) ,
G\sriio-lNJKsiiNAL DISORDERS, IMMUNIT\
(Cftrtttia), METEOROLOGY (Seasonal Ptevafence) ,
MICRO ORGANISMS, WAIKR (Dtwiiev produced
%)
SYNONYMS — A^ntu cholera, Fr iliottra , Gcr
litethruhr, Gallenyucht , It colera atiatieo
The Indian names are wton/tt, motdedun, m-
\inhi ka 01 biiuche, haizfi, sitani/n, waba, etc
DhuiVAiioN --The word cholera \\as applied
by the Grook and Roman physicians to the
disease known as summei cholera 01 cholera
nostras Its etymology is unceitam Celsus
supposed it to be dcnved fiom x°^')> bile, and
/>cw, to flow , otheis, with Alexander of Tralles,
demo it tiom xoA-«Sts, the intestine, and ^c<u,
to flow, while some recent authorities incline to
the viow that it comes fiom \o\epa, the gutter
of a rooi
BACTERIOLOGY — In 1884 Koch discovered
the comma bacillus or vibrio, vhich is now
generally recognised as the e?i<t motbi of cholera
Pure cultuios of the uiicrobo arc undoubtedly
capable of giving rise to the disease m man ,
and if the evidence derived from the experi-
mental pioduction of the cholera m the lower
animals is more ambiguous, this ansos from the
fact that cholera is essentially a human disease,
which does not give riso to the same tram of
symptoms m the lower animals that it does m
man So much unanimity now obtains respect-
116
CHOLERA, EPIDEMIC
ing the pathogenic character of the vibrio, that
it is unnecessary to recount the accidents and
expeiimonts which establish beyond doubt that
all the symptoms and lesions of cholera can be
caused by it in man, 01 to discuss the value of
the evidence affoided by experiments on the
lower animals
The vibrio is found in the stools of choleia
patients, and aftei death in the contents and
tissues of the intestinal canal It has occasion-
ally been detected in the vomited matters, but
only in small numbers, and its presence m the
vomit is doubtless to be accounted for by the
contents of the intestine finding their way into
the stomach It has also been met with in a
few instances in the bile ducts and gall-bladder
It is never present in the blood, livei, spleen,
kidneys, 01 mcsenteiic glands The leal seat
of the microbe is the lower part of the small
intestine Abel and ('laussen made the im-
portant observation that vibrios are often
present in the stools of healthy peisons who
are in daily intercourse with cholera patients
They have also been found in the stools of
convalescents up to fifty days after recovery
When one of the small mucous flakes fiom a
cholera stool is spread out on a covci- glass,
dried, heated, and stained, the bacillus is
readily to be seen if the specimen happens to
be a pretty pure cultivation, otherwise the
presence of other organisms makes its detection
difficult In many cases its piesence or absence
can only bo ceitamly detei mined by placing a
mucous flake in peptone broth, and incubating
for twenty-four hours , the vibrios in sufficiently
pure culture for microscopic examination aie
then to be found on the surface of the fluid
The \arious media and processes of cultivation,
and the distinctive chaiacteis of cholera colonies,
will be found doscnbod in any text-book on
bacteriology
The choleia bacilli are actively motile, flagel-
lated, curved tods, alxjut half the size of the
tubercle tacilhu Their aveiage length is
about 1 5 /* , their thickness flora one-sixth to
one-third their length The young foims show
only a slight curve, the older ones a moie
decided bend, while some present the form of a
half-circle They occur isolated or attached to
one another in the foim of the letter S, or in
longer scio\v-hke foims They aio stained with
waim solutions of methylene blue, or with
methyl-violet, or fuchsine
They do not thrive m acid media They aio
aerobic, but are nevertheless capable of growing
to some extent when oxygen is altogcthoi ex-
cluded The cultivations made with a deficient
supply of oxygen are more virulent, but less
resistant to the action of the gastnc juice and
external mtluciucs than those grown with a
more abundant supply of oxygen It is the
circumstance that they are capable oi growing
when only a slight amount of oxygen is present
hat explains their lapid multiplication in the
ntestmal canal. This may also explain their
axaltcd toxic power as parasites, a toxicity
which they lose when grown for a time as
aprophytos with a free supply of oxygen
The choleia bacillus does not grow below
6° , it thriven between 22" and 25° , its opti-
mum lies between 30° and 40° V It is killed
)y exposuie for half an hour to a temperature
of 60° Although the bacillus docs not grow
jelow 16°, Koch iound that it is not killed by
:>emg subjected for an hour to a tompciaturo of
- 10° C It is very susceptible to drying,
[voch sa>s that when spiead out on a cover-
j;lass and exposed to the air, the bacillus is
tilled alter two or thice hours, but accoi ding
to Kant I lack the vibnos have been found to
retain then vitality foi 120 davs when dried on
glass When exposed to sun and air they do.
not live long on a covei -glass, but if the air is
humid, and the preparation is not exposed to
sunlight, they aie not so easily destroyed
Commas aie easily destroyed by the growth
of sapiophytes, but experiments beaiing on this
point give widely difleient results The nature
of the medium, its teaction, and the class of
organisms it contains .ill no doubt count for
much Koch found that when added to sewage
the vibnos could not be demonstrated after
twenty-four hours , on the other hand, they
have been observed to letam then vitality for
months in sew age -polluted water Koch did
not mid them to survive longer than six or
seven dajs in the water of the Berlin Canal.
Orgel found that they could live for nearly
twelve months in ordinal y Kibe vvalei They
grow at hist \cry luxuriantly in moist soil, but
alter a few days they generally succumb to
saprophytes They retain their vitality for a
long time on moist linen, on winch they are
often found in a state of pine culture The
vibno is not \ery iastidious as legaids food
It grows on agar-agai to which meat infusion
and peptone luive been added, in slightly
alkaline nutiient gelatine, on solidified blood
seium, on potatoes, milk, and, to some slight
extent, even in sterilised water Tins shows its
adaptation to saprophytic growth
So far wo have been dealing with the char-
acters and habits of the miciobo as observed in
expeiimcnts Little is known of its hfe-histoiy
outside the human body, but what httlo wo
know shows that it can retain its vitality longer
than cultivation experiments would lead us to
anticipate The microbe under natural con-
ditions is a haidior plant than many suppose
In the sewage -polluted watei of Marseilles
harbour it has been found to survive foi eighty-
one days There is reason to bclievo that it
may exist not for the few days which experi-
ments indicate lor its limit, but for months,
perhaps for years, in the soil (tee article on
"Epidemiology")
CHOLERA, EPIDEMIC
117
But while tho cholera vibrio is capable of
retaining its vitality, it loses much of its vnu-
lonce when giown for a time as a saprophyte,
and the more vigoious its saprophytic giowth,
the loss its virulence From Hankm's observa-
tions this loss of vnulencc is observed even in
India, wheio tho conditions might be supposed
to be pccuhaily favourable for it retiming its
properties Not only docs it lose in virulence
when grown continuously outside the body,
but it also undergoes maikcd morphological
changes
It is admitted that the vibnos met with m
cholcia stools present considerable differences,
which tend to perpetuate themselves through
successive generations Some have one flagel-
luni, others more Less definite distinctions in
size and toim are also obseived Differences,
too, exist in tho appearances piesented by the
colonies they fonn on gelatine plates and in
their power of liquefying gelatine, and all this
has given rise to discussions as to the unity 01
multiplicity of tho goi m The marked morpho-
logical and biological changes in vibrios, derived
from a common stock, which are obseived to
occur under cultivation, piove the variability of
tho oigamsm, but tho essential unity of all the
varieties is attested by then common patho-
genic piopeities, and by tho immunity which
tho vaccine of one vanc-ty coiifcis fioin attacks
of all the otheis
When tho cholera vibno is cultivated in the
peritoneal cavity of the guinea-pig its vnulcnce
is me leased, and it is by passing it in this way
thiough a succession of guinea-pigs th.it Haft-
kme obtains his piophylactic vnus A cultuie
from the peritoneum iunaslios a pure sub-
culture on ag.ii, whuh is thoioughly shaken up
with btoth This constitutes the vaccinating
mud, which may be used as a living vaccine, 01
the bacillus may bo killed bctoie being used
Very great interest and impoitance atta<hcs
to the investigations of Mctschmkoft bearing on
the influence of non- pathogenic oigamsms in
promoting in hindoimg the development of the
choleia vibrio on extoinal media, and in deter-
mining infection m animals He found that
some species of sarcin.o, toiul.e, and a variety of
the colon bacillus promoted the infection of suck-
ling labbits Tho associated organisms rapidly
disappeared, but none the less they subseived
to the development of the choleia viius m
those animals When we remcmbei the effect
of moulds in piomotmg the growth of the
bacillus of yellow fevei, and of stieptococci in
intensifying the vnulence of tho diphtheria
bacillus, we feel that it is in this association of
non - pathogenic organism \vith tho cholcia
bacillus that we are likely to find an explana-
tion of some obscure points in the etiology and
epidemiology of the disease
The manner in which the comma bacillus is
influenced by temperature, moisture, rainfall,
and drought throws considerable light on some
of the epidemic featuics of choleia
(«) The relation of the vibiio to temperature
explains why m temperate climates cholera epi-
demics are mostly restricted to summer and
autumn It is in these seasons only that the
temperatuio permits its saprophytic growth
(ft) The effect of diymg on the vitality of the
parasite accounts foi cholera dying out during
the long diy season in the Punjab and Cential
Provinces, and its reappearance attei the ram
begins to fall, when tho earth and atmosphere
become moist and humid In such legions tho
choleia season is regulated not by the tempera-
ture as in Europe, but by the lams
(c) The inability of the vibrio to live for any
length of time m fluids deficient in nutritive
material, as \vell .is the effect of excessive moist-
uie of the soil m reducing the oxygen at the
dis]X)sal oi the organism, explain the subsidence
of the disease in endemic areas, when the heavy
lams submerge laige tracts of land, and displace
the air from the soil that remains uncovered
ETIOIXJGY — For a widespread cpidemy of
cholera the following conditions are necessary —
(1) Tho piesence of the miciobc , (2) a suitable
medium and temperatuie for its giowth outside
the body , (3) means of transpoit from place to
place, (I) a vehicle by which it can be diffused
in a paiticulai locality, (5) a susceptibility for
infection on the pait of a community
1 *SVw/te"r of the Vnus — The primary source
of the \irus, outside the legions in which cholera
is endemic, is m every instance the intestinal
dis< harges of a person suttcimg from, or one who
has lecently sutteied fiom the disease, or of a
pei son who without sunVimg from the disease
hai hours the miciol>e, from having associated
with a cholcia patient
It will seldom happen, however, that the
imciobe giown in the intestinal canal of a cholera
patient will hud its way ducctly into that of a
healthy person, for cholera discharges will only
bo swallowed accidentally, or as tho result of a
scientific experiment It is the descendants of
this mit iota giown in some external medium —
water, milk, soil, linen — winch in most cases
causes infection
2 ]itfe<hnq-plac<.<* — The virus having been
introduced into a l<x ahty must find some medium
outside man m whuh it can grow Such media
are («) a soil polluted with organic matters,
especially excreta , under soils we include
accumulations oi animal and vegetable refuse,
cesspools, etc , (ft) scw.ige-polluted watei , (c)
milk and othei aiticles of food
Having found a suitable medium, the bacillus
requires a certain temperatuie for its growth
Cholera was introduced simultaneously into New
York and New Orleans in December 1846, and
broke out m both cities , but m New York the
outbieak rapidly subsided, whereas in New
Orleans it spread during the winter This
118
CHOLERA, EPIDEMIC
difference will be easily understood when we re-
member that tho winter temperatui e of New York
is under freezing-point, while that of Now Orleans
is about 60° F How favourable soever other
circumstances may be, an extensive epidemy of
cholera cannot occui in winter in higher lati-
tudes, except under very exceptional conditions
3 Means oj Trannpot t — Tho viow that the
cholera vuus can bo tiansported for long dis-
tances by the air is quite untenable Biydcn
maintained that atmospheric moisture is the
earner of the virus, and that its distribution
over India extends as far as the moisture-laden
monsoon winds carry it The rains supplied by
the monsoon act in a different way , they bring
the soil into a condition htted for tho spread of
the pestilence Tho germs of the disease are
always being carried from Bengal to tho noith-
west, but they do not develop epidemic outbieaks
until the condition of the soil favours the growth
of the microta
The principal means by which the vims is
transpoitcd from place to place, HO as to over-
run vast regions, are (a) huiiuin mtet cout se, that
is, by persons who have, or have had, the disease,
or who harbour tho vibno, and things con-
taminated by cholera discharges That this is
the principal means of its propagation is proved
by the constant y w ith w Inch choleia has follow ed
caravan routes and lines of communication by
river, road, lail, or ship, and by its lapidity of
spread increasing as inteiconise between distant
countiics becomes mote rapid In its early
invasions of Europe, cholera followed the routes
of caravan tiaffic. Cabal h«is always received
the infection from India, and has been the con tie
from which it has adv anced w ostw ards One route
fromCabul passed through Central Aaia,byBalkh,
Bokhara, and Khiva to Oienburg, anothei through
Persia by Herat, Mcsched, Astrabad, Teheian,
Reshcd, Baku, and Astrakhan An alternative
route from Teheran led through Tabiees, Tiflis,
Erzoioom, and Tiobo/ond to the Blade Sea In
the same way cholera mvanably bleaks out in an
island at ports in communication w ith an infected
place In Russia in tho olden time choleia
followed the livers, and on its first outbreak in
England in 1832 it followed, as Hirsch points
out, " tho commeicial highways chiefly, and the
coast routes and rivers, while the mountainous
parts of the country were little visited by it, and
the Scottish Highlands not at all "
When wo remembei that choleia has been five
times epidemic in M ami tin 8, and that on each
occasion it has bioken out shortly after the
arrival of vessels from India with the disease on
board , that it broke out at Quebec in 1832 four
days aftei the arrival of tho CamrJ, on board
which cholera had pi e\ ailed during tho voyage
(and the Western Ilcmisphcie had never up to
that day been MHited by the disease), that it
appeared at Now Yoik in 1848, which was then
free from the infection, on the arnval of a vessel
which had lost seven passengers from cholera ;
that it appeared at New Orleans in the same
yeai, thice days after the ai rival of the ship
tfi/xrntwt, thirteen of whose passengers had died
of cholera during the passage , and when we see
it bieakmg out along the routes of pilgrims,
tracking tho march of armies, following the lines
of emigiation, we will be driven to the conclusion
that human inlei course is the most important
of all the means by which cholera is transported
from place to place, fiom one country to auothei,
across deseits and oceans
(l>) Rivets — A stioam polluted by choleia
discharges may cany the virus for very con-
sidciable distances to towns situated on its
banks In the last outbicak in Gcimany the
fiontier nvcr Pr/ems/a, a tubutary of tho
Vwtulti, had become polluted by the cholera
virus Shortly afterwaid, cases began to appear
among the nvei lattsmen and bargemen on the
Vistula The < holera bacillus was found in tho
water of the river above Dantzig, wheic cases
now began to appear By the middle of Juno
at least six (Jeiman towns and villages on the
banks of the nvei had become infected (see
Local (,'ovet nnumt Repot t, 1897-98)
(() M//>s, which aie moving centres of in-
fection, transpoit the vnus across oceans This
usually happens thiough tho agency of infected
persons, but it may also take place by means of
infected goods, ballast, 01 bilye water
4 The diffusion of cholera in a given locality
is a question distinct from that of its tiansport.
(a) The vehicle by which it is most frequently
conveyed into the system is dnnknnj water.
When the vnus finds its way into the genet al
watci -supply of a city, as was the case in Ham-
burg in 1892, the disease becomes i.ipidly and
widely diffused When wells become polluted
we have local outbreaks, as happened in tho
well-known Bioad Stiect explosion in London in
1854, in which the disease was practically con-
fined to those who made use of a contaminated
well, and ceased from the day on which the well
was closed
The impoitant pait played by watei in tho
spread oi choleia is seen in the decrease of the
disease in towns in which it was foiraerly pi ova-
lent on the intioduction of a pure water-supply.
The average mortality of the European troops
at Fort-William, Calcutta, was 20 per 1000 from
1 8 26 to 1 863 Fi om the latter date, w hen the fort
was for the first time supplied with pure water,
to the piescnt time it has averaged 1 per 1000
Lahore had an average cholera death-iate of
1 07 per 1000 for the fifteen years 1848-01 In
the period 1882-87— that is, after the intro-
duction of water into the city from the Ravi
River— it fell to 0 07 pei 1000 That the re-
duction in the cholera death-rate has really been
duo to the unproved water-supply is pioved by
the fact that in tho Lahore district (excluding the
city) tho cholera mortality, which was 034 in
CHOLERA, EPIDEMIC
119
the former series of years, rose in the latter
period to 0-43 per 1000
(b) Milk attd ot/ter articles of food are not
only media for the growth of the VIIIIH, hut
vehicles for its diffusion. In beets doubtless
play an impoitant part in spreading the disease
by bottling on articles of food after having been
in contact with substances containing the vims
The house-fly in partic'iilar is an active agent in
disseminating the geirns of the disease in this
way, and now that it has been shown that the
vibiio is capable of living foi at least fourteen
days in the fly, wider limits must be assigned
to its pernicious activity than was formerly
conceded to it
(c) Ait a* a Vehicle of Infation — Hirsch,
writing m 1883, says, "The facts do not permit
us to ignore that the poison mutt be taken up
and suspended in the air, so as to entei the human
organism with the bieath " This \vas how the
facts looked to so eminent an epidemiologist a
few years ago The facts icmain the same, but
the way in which they aic looked at and mtei-
prctod has so completely changed, that to many
it seems now incredible that the vims e\ci
enters the system by means of the breathing
air It is held that micio-orgamsms can only
be deUuhed fiom perfectly diy sui faces, so as
to be earned about with dust in the atmospheie,
and as the choleia vibiio is supposed to be un-
able to beai this amount oi drying, infection
through the atmosphere is rcgaided as impos-
sible The piemises are doubtful, and the con-
clusion contiaiy to \\ell-obseived facts That
choleia is not usually diffused by means of
the air is evident enough, but air is neveithe-
less one of the vehicles by which the \iius
enters the economy It is not to be supposed
that infection takes place thiough the lungs
The vibiio lodged in the uppei an-passages may
live 01 even multiply in the alkaline mueosities
of the paits, and then be conveyed into the
stomach along with food
As space forbids us entering into detail, \\e
shall content oui selves by buefly lefemng to
two categones of facts illustiatmg the occasional
aerial convection of the choleia virus
To the fiist category belong paiticular in-
stances m which the infection has been cained
from the sick-room, and those in \vhich simple
pioximily to a source of infection has gnen use
to the disease Copland rccoids an instance m
which all the circumstances seemed to demon-
strate that he earned the infection on his clothes
for a distance of about n mile and a half and
communicated the disease to t\\o of his relatives
(Dictionary, article " Epidemics ") Similar in-
stances are by no means mio Simple proximity
to a source of infection may also give rise to
infection Cholera broke out on the steamship
Ensjland from Liverpool There had been 150
oases and 48 deaths on boaid when she bore up
for Halifax A pilot hailed the vessel, but
having learned that there was a fatal disease on
board, he laid his boat close alongside, sent up his
papers to the captain in a basket that had been
lowered from the ship, and brought the vessel
up to the quarantine station without luvmng
lowtlfd her, and then rowed ashore with his two
comrades Two days after having come thug
remotely into contact with the Enylaiid he was
taken ill of cholera, and thifce days afterwards
cholera bioke out in his family Almost at the
same time one of his two companions sickened
and ga\o the disease to three of his childien
The Western Hemisphere had then been three
yeais free from cholera (liirsch) An instance
of approach to a dead body being followed by
choleia is given by Clemow in the Transactions
of the Ejn</tmtolo(fica? Society for 189.3-94
To the second category belong the sudden
explosions of a number of cases of cholera on
boaid vessels m which the disease had before
been ou in ring m a spoiadic way, after a storm
dm ing which the poits and other means of
ventilation have had to be closed These
scarcely admit of any other explanation In-
stances of this kind aie given m detail by
Smart
The Jintannia ship of war, for example, in
18H4 was infected while lying at Buljick, where
cholera existed Up to the 10th of July three
deaths had occuncd She put to sea on the
1 2th, and the disease seemed to subside at once.
On tlie evening of the 13th a gale necessitated
the closing of the poits on the sleeping-deck
About 10AM on the 14th "a great and sudden
outburst of collapsed cases occurred " There is
nothing m the circumstances in such instances
(and they aie numerous) to mcimmiate water or
food, but evei^ thing points to the virus diffused
thiough the air of ciowdcd and un \entilated
holds causing these sudden explosions
5 Individual susceptibility counts foi much
in the matter of infection It is only a small
proportion of a community th.it is attacked
dining an epidemy Excesses of all kinds,
especiall} alcoholic- excesses, causing gastroin-
testinal catairh, predispose to cholera A com-
munity acqun es an immunity lusting for three
or foui jears aftei passing thiough a severe
epidemic of cholera
A few ciicumstances relating to the etiology
of eholeia lequire to be mentioned —
(a) TojMH/HijJnca/ Relation* — Cholera shows
a special predilection foi the low -Ij ing parts of
a town Fait laid it clown as a law "that the
proportion of deaths from choleia is inversely
as the elevation of the ground," and this law
holds good excepting in instances in which
the incidence of the disease is determined by
the contamination of a w ate i- supply As an
endemic disease, cholera is limited to altitudes
not exceeding 1500 feet As an epidemic
malady it has broken out at elevations of 6000
feet (Kussouh, 1845)
CHOLERA, EPIDEMIC
(6) Racial Relation*. — The following propor-
tions per cent were attacked at Guadeloupe in
1865:-
Chinese
Whites
Hindoos
Mulattoes
Negroes
2-7
4-31
3-26
6 31
9-44
The comparative immunity of the Chinese
has also been noticed m Mauritius, and has
been ascribed to their opium-eating habits, but
it is to be remembered at the same time that
nowhere has cholera raged more destructively
than in the Chinese Empire
(c) Personal Relation* — Sex has no influence
on the liability to cholera Its incidence on
different ages vanes in difFcicnt outbreaks In
the Hamburg outbreak of 1892 the ages fifteen
to twenty-five gave the smallest ratio of attacks
and also of deaths to the numl>er attacked
Children under two years of age buffered con-
siderably, as did also fid persons The JMXW,
as a rule, suffer more than the iich, and u
special liability attaches to tLc inmate* of
Lunatic Asylums As respects occupations
little can be said, except that \\ashct\\onien
employed in washing choleia linen contract the
disease out of all proportion to its incidence on
the community geneially
Exempted Plate* — Some places seem to be
proof against cholera It lion never appealed
m Cheltenham, Sedan, or Wur/lmrg In othei
places, such as Versailles, Lyons, and Martinique,
the disease has nevei assumed epidemic pio-
portions
MORBID AN ATOM \
When death occurs at the height of the
disease, rigor mortis is well marked , the featmes
are pinched, the face, extremities, and body
generally are mote or less cyanotie
The cerebral Minuses and the veins of the
menmges contain dark blood
The pleuioj are diy, and frequently piesent
numerous ecchymoses The lungs are diy and
collapsed, and aie much below the normal
weight The laiger branches of the pulmonary
arteries contain blood, the smallei arteries,
capillaries, and pulmonary veins are empty
The pencanlium does not contain a trace of
scrum The visceral layer is frequently studded
with small ecchymoses The right side of the
heart and the veins* emptying into it, as \vell
as the jugular veins, the portal vein, and the
larger hepatic veins, are engorged The left
side of the heart is empty and contracted
The stomach is empty , the lining membrane
may bo pale and sodden or congested Occa-
sionally it presents ecchymotio points The
duodenum and jejunum are frequently hyper-
semic continuously or m patches
The large intestine is contracted The peri-
toneum covering the small intestine has often a
rosy appearance and is dry and sticky. The
ileum usually contains more or less rice-water
fluid, and is throughout, especially m its lower
part, congested and oxlematous, but these
appearances are most marked in its lower half.
Occasionally the mucous membrane is found
pale, instead of congested; at other times
ecchymosed and suffused The solitary glands
and Peyer's patches are prominent, the latter
often surrounded by a red zone of congestion
On microscopic examination the mucous mem-
brane in many parts is found denuded of epi-
thelium At other places the epithelium is
detached from the subjacent tissues by serous
exudation Commas are found m the tubular
glands, and between the epithelium and the
basement membrane, on the surface of, and
sometimes within the villi, and occasionally also
m the deeper tissues oi the inuoosa The mcs-
entenc glands are swollen and softened
The liver is often somewhat increased in
volume, daik, congested, but of noinml consist-
ence The gall-bladder IH hill of bile of varying
viscidity and coloiu The spleen is small, diy,
and anrcuiK
The kidneys, when death occuis eaily, aie
often augmented in volume, and in this case
the medullary and coitic.il substances show
punctuated, patchy, 01 striped aie.is of venous
congestion, occasionally ecchymotic points or
patches The vessels of the glomcnih are con-
gested In other cases the congestion is less
marked, and the kidneys may even be pale
The epithelium of the tubules is swollen and
cloudy, blocking up the lumen of the tubes
The bladdei is empty and contracted
When death has occnned dining the sta^e of
reaction, the appearances are altogether differ-
ent fiom those just described, and the lesions
vaiy considerably according to the symptoms
developed dining the reaction
Thf (cicbial membranes aie injected, and
theie is often effusion into the meshes of the
pia mater and into the lateral ventricles The
lungs arc congested, and the pneumonic or
other inflammatory lesions may be present
The mucous membrane of the small intestine
may be softened, ulcerated, 01 covcicd with
patches of diphtheritic exudation, and this may
extend to the large intestine' The liver and
spleen are usually somew hat enlarged and con-
gested, the kidneys enlarged, vascular, of a
dark red colour, with fatty and granular casts
in the canahcuh The urine in the bladder is
generally albuminous
SYMPTOMS
The cardinal symptoms of cholera are diar-
rhoea, vomiting, muscular cramps, paresis of the
heait, algidity, suppression of urine, followed by
death or reaction
The attack may begin with a diarrhooa m-
CHOLERA, EPIDEMIC
121
distinguishable from an ordinary diarrhoea ex-
cept by bacteriological examination of the dis-
charges This premonitory diarrhoea usually
lasts from half a day to two days before the
choleraic symptoms declare themselves, and
when promptly treated, the disease is frequently
arrested at this stage This premonitory stage
is often enough absent
The actual attack begins with frequent, oop-
lous, watery evacuations, at first coloured with
bile, but soon becoming ]ule, having an alkaline
reaction Along w ith this there is urgent thnst,
great discomfort in the bowels, an indescribable
feeling at once of intolerable distension of the
abdomen and sinking that cannot be understood
by those who have not experienced it, nor
forgotten by those who have There is no
toncsmus
The stools become more frequent j»nd copious
They flow m sti earns No sooner h,ts the
patient evacuated, as he thinks, the whole eon-
tents of the bcwol and hopes to obtain a little
respite, than he is again distmbod, and again
passes an enoimous quantity of an odourless,
colourless, rice -watei liquid, which on rest
deposits hue, flak;} o.u ticlcs
Aftei a time -vomiting sets in, and so much
the sooner, thu moie freely the patient has
giatified his Liaving foi water Large quantities
of a pale liquid are ejected forciblv, but without
effoit, fiom the mouth It seems as if it were
automatic .illy pumped out Thu patient is nou
extiemcly restless, tosses oil the bed-clothes, and
although his skin feels cool 01 c old, he complains
of heat The pulse is lapid and weak, the
hcait's action feeble The extremities become,
cold and blue, the nn^eis shmclled and livid ,
the tempciatuie in the axilla may fall to 94° 01
93° F , sometimes lower , that of the icctum is
seveial degrees abo\e the noimal, and it may be
well to lemaik th.it the rectal tempeiatuic is
often highei than noimal befoio the algid state
has declared itself It happens, howe\er, in
many cases that the i octal temperature follows
closely that of the axilla The \oico becomes
weak and hoarse — the1 so-called voi <Jio/eui(i,
the eyes aie sunken, the eyelids half closed, the
taco pinched, the hi oath feels as it it had passed
over ice, the tongue gives, as Dr Watson savs,
the sensation as if one were touching a frog's
belly , the urine is scanty 01 tmppicssod This
is the algid stage of cholera
When this state has begun to develop, 01 even
before, painful musculai cramps of the calves,
arms, and sometimes of the alxlommal muscles,
set in, which add greatly to tho suttenngs of
the patient They are tonic spasms, lasting foi
two or three minutes
When tho algid state is established, the
motions usually become scatitiei and loss fre-
quent, and are passed in bed Oi they may
entirely cease, being ictained from a paialysed
state of tho bowel — a symptom of CM! omen
Retching, alternating with hiccup, takes the
place of the vomiting
This state may last for a few houis only, or
persist for one or even two days — perhaps eight
to fifteen hours is the average— and terminates
in reaction or m death
When the diseisc is tending to a fatal issue,
patient sinks into an apathetic state, heed-
less of what is passing around him, but at the
same time conscious The heart's action grows
weaker, the pulse impcicoptiblo at the wrist,
scarcely to bo iclt even in the carotid, the skin
becomes ruveiod with a clammy sweat, and the
patient -lies in a state oi collapse
Bcfoie the n lucid stage has set m, or after it
ha > been established, things may take a favour-
able tin n bv the setting in of reaction The
pulse becomes fuller, slower , the impulse of the
heait "'roiiKcz , the bieathmg deeper, easier, and
less Imiiii'd, the rectal temperature falls, and
it is only af ter this that tho surfac e regains its
waimth The damps disappear, the retching
and purging subside, and the patient tails into
a tranquil sleep, fiom whii h he awakes refreshed
It is often not until after thirty six to forty-eight
houis that urine is passed The first urine is
of lo\\ specific gravity, containing moie or less
albumin, sometimes blood In favourable cases
the leeoveiy is rapid
But leaction does not nocessarilv nnpl) that
all dangci is ovci, for m many cases it introduces
a now series of troubles Tho loaction may be
impel feet, the dischaiges retur, thirst returns,
and the patient, when wo were Ix'ginnmg to
hope for lecovery, falls Kick into the algid stage
In othei cases he lapses into a typhoid condi-
tion maiked by great debility, moie or less
stujK)i, lestlessuess, especially at night There
is complete anoicxia, occasional \omiting, diar-
ihcca 01 constipation, 01 both alternately, with
metcoiism, scanty albuminous urine, containing
fibrinous casts After this condition has lasted
from four to seven days, the symptoms may
gradually impio\e, in this case the appetite
i etui MS, the tnino becomes moie abundant, the
albumin diminishes, and thu head symptoms
pass oft
In othei cases the symptoms become aggra-
vated, and the patient ialls into a comatose
state It has to be mentioned that typhoid
symptoms terminating in death fiom coma occa-
sionally occui, although the urine is abundant
and free horn albumin This typhoid condition
is all tho more likely to supervene the longer
the algid state is piolongcd Those who have
been addicted to dunk seldom ieco\ei without
exhibiting typhoid svmptoms, which in their
case aie c\cn more dangerous than in others
(iaugrene of the penis, scrotum, nose, and of the
mucous membranes of the mouth are tho rarer
sequels of cholera More frequently the parotid
glands become swollen and inflamed, and some-
times suppurate
122
CHOLERA, EPIDEMIC
The duration of the disease in fatal cases
varies greatly A few die from four to eight
hours after the commencement of the attack,
more from twelve to forty-eight hours The
algid state seldom Lusts beyond the second day
Those who survive this, die in the typhoid stage
from the fourth to the tenth day After the
tenth day recovery is to be expected
ANALYSIS OF SYMPTOMS
DiarrJwea — The watery, pale stools of cholera
are alkaline in i cacti on, have a specific gi.mty
of 1005 to 1010 The (hied deposit from a pint
of cholera dejections was found by Parkos to
weigh only 4 grains Examined inicioscopually,
the stools are found to contain mtobtin.il epi-
thelium, disassociated or in small flakes, with
granular matter lesultmg perhaps from the dis-
integration oi epithelium along with mucous
corpuscles Before the penod of reaction the
btools will be found to contain flakes of mucus
containing commas in almost pine cultivation
In the reaction stage these are less readily to be
detected, other micio- organisms then abound,
and blood cells, not common in the fust stage,
aie now frequently pre ent
Cheuucullv, the nce-\vatei evacuations contain
a small quantity of albumin, chloudc of sodium,
and carbonate of ammonium , occasionally, but
very seldom, traces of urea
The diarihooa is the pi unary and constant
symptom of choleia In what lias been inap-
propriately called iholeni jwra, in which theio
is neither diarrhoea nor vomiting but rapid
collapse, the bowels aie after death found dis-
tended with ncc-watcr fluid, transuded but not
evacuated The bowel in this dangerous foim
of the malady is paralysed
Whether the diarrhoea be caused by the pres-
ence of the bacillus in the mucous membiane,
abstt acting from the blood the liquid necessary
for its glow th, or by a toxin foiined by the
bacillus, has not been ascertained
Diaiihcua is only a symptom, it is tine, but
it is a symptom producing othei symptoms,
formidable in itself and in its results The
drain of fluid from the system causes inspira-
tion oi the blood, this in turn leads to the
absorption of watoi from all the tissues Hence
the sinking of the eyes, the pinching of the
features, the coriugation of the skin of the
fingers This draining off of the wateiy pait
of the blood, if not the sole, is an important
factor in the arrest of the uiinary secretion
The blood does not contain the material for the
secretion of mine, but as contributory cause
of suppiession we must reckon the diminished
pressure of the blood in the kidney, fionx the
enfeebled action of the heart But this caidiac
failuie is itscli, again, paitly the result of the
thickening of the blood caused by the diarrhoea
The urine is not the only secretion arrested.
The secretion of tears, sweat, saliva, and, m most
cases, of milk is arrested. We thus see that on
the diarrhoea many of the other symptoms of
cholera depend As a rule, when attempts have
been made to remedy the evils caused by the
loss of fluids, by means of injection of saline
solutions into the veins, the rapid improvement
of the patient's condition has shown how essen-
tially dependent many of the piominent symp-
toms oi the disease aie on the dehydration of
the blood , but the fluids injected in this way
are lapidly earned off again by the bowel, and
the patient is within a shoit time in the condition
in which he was before the fluid was injected
Vvmit —The vomit of cholera is pale or whey-
like, alkaline from caibonato of ammonia, and
seldom, and only accidentally, contains the
comma bacillus Among the toxic substances
isolated from cultivations of the choleia bacillus
no emetic principle has been discoveied, so fai
as we know Yet such a principle i» piobably
piescnt
Temjwatwe aiul C Deviation — The algidity
of cholera is to be ascribed to the depiessed
action of the heart, and also to the thickening
ot the blood impeding the circulation, especially
in the extremities The depiessed action of the
heait itself is not the tcsult of a single cause
liriegci has isolated a toxic pioduct of the
choleia bacillus which has the e fleet of low ei ing
the temperature and depicssing tho hcait's
action, but it is impossible to doubt that the
action of tins toxin in producing caidiacdepiession
and lowering of temperature must be increased
by the thickened condition ot the blood
Another choleia toxin has been isolated which
causes ciamps and muscular tiemois We aio
therefore justified in the present state* of know-
ledge in looking upon the muscular damps as
w holly or in part the result ot the cholera toxin
There is a still ruoie important phenomenon
for which we have no satisf.utoiy explanation,
namely, the* increased tempeiaturo of the m-
tenor of the abdominal cavity This appears
to be a pietty constant concomitant oi algidity.
The highci the lectal tempeiature, the gi eater
the danger On the appioach of death the
tcmpciatuic of the whole body has been found
to rise, and it geneially continues to use after
death
A fall of the internal tempeiature is a favour-
able sign, and is usually followed by an mciease
of the sin face heat When reaction is favour-
able the temperature in the axilla remains
normal or moderately elevated In tho typhoid
stage it rises above the normal
lieynratian — The carbonic acid in the expired
air is reduced from the impeded en dilation in
the capillanes of the lung
The Urine — The causes of the suppression of
urine in cholera have been already considered.
PROPHYLAXIS
Knowing the sources of the virus, the media
CHOLERA, EPIDEMIC
123
in which it grows, the modes in which it is
transported fiom place to place, and the vehicles
by which it is conveyed into the body, prophy-
lactic measures can now be applied with a pie-
cisiou and success that \veio formcily impossible
The poison ought to hr attacked .it its source
by the cremation or thoiough disinfection of
cholera evacuations In choleia hospitals it will
be bcttei to cremate the stools altei mixing
them with sawdust, but their quantity un-
doubtedly renders this method of disposing of
them difficult in private houses Carbolic at id
in 5 per cent bolution is the most useful disin-
fectant ior general use Bichloride ot mercuiy
solution, 1 per 1000, with addition of fiee
hydiochlouc acid to prevent the formation ot
albuimnate ot meicury, is an effective germicide,
but its poisonous propoi ties aie an objection to
its general use Chlondo of lime, 10 paits in
solution to 100 of faxes, may also be used The
disinfected stools should be buried at a distance
frc-m wells Clothes may bo disinfected by boil-
ing, but as a preliminary the} should be fumi-
gated with sulphmous acid Oi disinfection by
dry heat may he used Soiled linen and other
articles of little value should be binned Fm-
nituie and utensils should be cleansed by wash-
ing \\itli carbolic acid, 1 in 20, added to hot
\vatci , they should then bo exposed to the sun,
so as to be thoroughly dned Rooms and cabins
of ships may be disinfected by sulphurous acid
or (hloiine For e\e,rv 1000 cubic feet 1 Ib of
sulphur IH to be used ('him me may be evolved
by .idding hydiochlouc acid to chloride of lime
in the piopoition of 2J Ibs of ticid to 15 Ibs oi
the chloiule foi evciy 1000 cubic feet of air-
space For disinfection of a ship's bilge a 5 pel
rent solution ot caibomc acid, left to act toi
torty-eight hours, may be employed We must
also mention that Ilankin has great faith in
poriuangaiifite ot potash as a means ot dismlett-
ing cholera wells The peimanganate is added
at sunset, so as to allo\\ the sediment to settle
to the bottom Jn the moinmg the watci is fit
to dunk To 0111 w«»> of thinking, cholcia wells
should bo shut up whenever piacticable, and if
this is impossible, the watei should be boiled
befoio being used foi any pmpose whatsoever
The measmos demanded tor preventing the
transport of the disease aio the legulation of
pilgrimages in India, Mecca, and Mesopotamia
Effective sanitation of pilgum resoits, means for
isolating the sick, aiiangements foi the inspec-
tion of pilgum ships, their quaiantine when
necessary, and the disinfection oi the clothing
and other effects belonging to the infected
bands, come under this head
These are matters of international policy, on
which it is imnecossAiy to dwell Although
strict quarantine is impracticable in a country
like England, it is of great value in pi eventing
the introduction of the disease in islands and
countries where trade is not extensive and is
limited to a few ports when propeily and
humanely cained out
The measures for removing conditions favoui-
ing the growth of the germ — what I have spoken
of as bi coding-places or cultuie media — resolve
themselves into general sanitation Moist lands
should be drained, the pollution of the soil by
excreta, and the contamination of the watei s ot
harbours and streams by cttolera e\acuations,
and the discharge of sewage prevented Cess-
pools aic to bo disinfected and closed, and all
refuse and oigamc matters regularly removed
(Juttcis and seweis are to be kept m good order
Streets, y.uds, and houses should bo inspected
regularly, and measures taken to keep them m
a state of peifcct cleanliness If such means be
adopted, the germ will find no medium on which
to giovv, and even should the disease be impoited,
it is little, likely to spiead
Above all, caie must be taken to pie/vent the
pollution of dunking water, which is the vehicle
ioi the wholesale diffusion of the \nus No city
dependent on shallow wells 01 on sewage-pol-
luted riveis is sate fiom choleia outbieaks An
eihcient system of tiltiation (such as that sup-
plied by some of the London Companies) does,
howevei, inatenally diminish the risk attend-
ing the use ot sew age-jxjlluted watei When
a watei -supply has become polluted, the obvious
piecaution is to boil it befoic use
When cholera breaks out in bai racks, the
tioops should be marched out to a dry and
elevated locality having a pine water-supply
If tho infection peisists, the camping ground
should be changed The old rule of marching
at light angles to the wind may be safely
ignored The bai lacks should, in the meantime,
be disinfected and the watei -supply looked into.
Choleia outbreaks on c low (led \essels are
always difficult to deal with, and not easy to
pie\ent Caieful dailj inspection, the isolation
ot the fust (,ises, and attention to cleanliness,
and, above all, hcc ventilation aie the most
hkeh means to pi event the spread ot the
maladv It tho weathei bo tine the patients
should be put into boats, hung horn the davits
and fatted up with awnings, and the utmost
attention paid to tho disinfection of the berths,
( abins, and the belongings of tho sick
Gnu other means ot piophylaxis which affords
a icasonable hope of immunity is tho method of
vaccination pi.wtised by Haffkine Ot 5357
laboureis employed in the Cachai tea-gaidens,
2381 were inoculated, while 2976 remained un-
protected , 4 of the inoculated and 60 of the
umnoculated died In other woids, the deaths
were proportionately twohc times moie numer-
ous among the unprotected
Unfortunately the protection does not appear
to last alx>ve a yeai 01 a year and a half, yet
the value of this method in the case of bodies of
men having to live for a bruited time in an aiea
where cholera is endemic, or in the case of a
124
CHOLERA, EPIDEMIC
community exposed to an epidemy, cannot bo
overestimated If further experience should
confirm the reports of the results obtained from
these vaccinations, the tenors of cholera will
be greatly diminished
DIAGNOSIS — With the aid of a bacteriological
examination of the .stools, theie ought now to
be little difficulty in distinguishing severe cases
of simple diarihum fiom cholera, A \\ ell-
marked case of cholera cannot be mistaken tor
any othet disease, except, perhaps, the choloiaic
form of malarial attack, but attention to the
history of the case, combined with a micioscopic
examination ot the blood and freees, \\ill clear
up the diagnosis Poisoning by arsenic, anti-
mony, and coriosrvo Hiiblimate present many of
the features of cholera, but the choleia stools
are chaiactonstic
PROGNOSIS — We need not say that in a
disease which on an average can ION off one-half
of those attacked, the prognosis should always be
guaidod The disease is most fatal in the ex-
ti ernes of life and in piegnant women Great
prostration, well-marked cyanosis, involuntary
discharges, or cessation of the dianhuea without
any sign of rcac tion, and the occurrence of
stupor and pei sistont amma after icaction has
set in are all of evil augury On the othei
hand, a fall of the t octal tempcratuio, an in-
creased fulness of the pulse in tho algid state, a
normal tempciatuio and absence ot typhoid
symptoms after leaotion has sot in, and a urine
abundant in quantity and tree horn albumin
are hopeful signs
TREATMENT — Although the indications for
treatment are now better undei stood, wo ha\e
as yet no moans of successfully mooting those
indications In rospoct to cholera the advice of
Hippocides should ncvei be foi gotten, "to do
good and do no harm "
The rauwl ttuficntton* aie to dostioy the
microbe in tho intestinal canal 01 inhibit its
growth
The tymptonuittc indications are to ariest tho
diairhcca and vomiting, to restoic tho fluidity
of the blood, to sustain the heait's action, to
restore waimth to the external surface of the
body, and alleviate the intense suffering caused
by the cramps.
In attempting to fulfil tho causal indication,
croslmn, creosote, t resole, and salol wore tiled in
Uiunbuig, but none of them proved of any ad-
vantage Calomel did, however, seem to do
good, and tho benefit losultmg from its use may
be ascribed to its gormicul.il properties One or
two ft-trram doses may be given to begin with,
and then 3 grams every NIX hours (Tndoi the
tieatment the diarrhoea often augments for
several houis and then diminishes Besides
calomel there is no internal remedy that can bo
safely employed to meet the causal indication,
and it must be confessed that calomel does so
imperfectly
Consideiable success, however, appears to
have followed the use of warm tannic acid
enemata lecommcnded by Cantani and others,
and, if we mistake not, they were found to be
of some service in Hamburg when given in the
first stage of tho disease The tannic acid is
supposed to destroy the cholera bacillus and
neutiahse its toxins, and it may do so, but the
question is, can tannin enemata reach tho seat
of tho disease? Cantam's formula is Tanmc
acid, grammes, 3 to 6 , gum-arabic, grammes,
30 to 50 , laudanum, 30 to 50 diops , infusion
of camomile, at 30° (5,1 litre
The Diamhaeu — Theio is something approach-
ing unanimity as to the advantage of arresting
tho premomtoiy diarrhoea It is believed that
the diso.iso may frequently Ixs cut short in this
stage by the use of astungeiits and sedatives,
and their employment is also indicated in the
fust stage ot the dc^ eloped disease When
algidity has set in the dkinhaM usually abates,
at any late absoiption is then so completely
ariosted that this class of remedies would then
be useless Compound chalk powdoi, opium in
combination with sulphuiic aud or with acetate
of lead, are tho icmedies most tioquontly re-
st n ted to in older to check the dianhoM
Craves consideied acetate of lead and opium to
bo tho best pieparation Ho recommended
twenty giams of acetate of lead and one grain
of opium to be dnicled in twohe pills, one to bo
given oveiy hall hour until the dischaigos began
to dimmish, and ho sa>s that "m all cases
whole medicine piomised any t banco of relief,
this lemody was attended with the \ery best
effects" Pel haps no moie reliable icniedy to
chock tho diatrhoea can l>c named than acetate
of lead in combination with opium
Vomiting — Foi the anest of \onntmg ice in
morsels, chloroform sinapisms ovei tho stomach,
calomel in large doses— say Ifi to JO grams —
imiHtaid emetics, aud many othoi lemodios have
been tiled None appear to succeed better, or
so well, as a tablespoonful of mustard in a pint
of waim water Sometimes a massive dose of
calomel will quieten tho stomach when othei
means ha\e failed In the less se\ore cases,
ice, and a largo mustard poultice over the
stomach, will piovo of soivice
Collate — We have soon that the diaumig oft
of the water from the blood contiibutos to the
arrest of tho secretions, to the onfcobloment ot
tho heart, and the consequent algidity The
injection of saline fluids into tho veins has often
been followed by a tempo* ary impiovement in
all the symptoms , but tho injected fluid is
rapidly discharged by tho bowel, and tho
patient falls back into the hopeless state of
collapse fiom which the injection had for the
time rescued him Some recoveries have
followed this plan of treatment, but its em-
ployment has generally ended m disappoint-
ment, and it is not even devoid of danger A
CHOLERA, EPIDEMIC
125
safer, but generally an equally unsuccessful,
method of supplying the loss of water to the
blood is that of injecting water into the sub-
cutaneous tissue A formula which may be
used, if it should bo thought pioper to try
this remedy, is Water, 1000, chloride of
sodium, 4, caihomito of sodium, 3 The fluid
itself and the uistiumentH must be stenhsed
If this IH done 110 haim will ensue, and m a
desperate case this remedy might be ti led
With the object of icstoiing warmth in the
state of collapse much benefit will otten be ob-
tained from placing the patient in a waim bath
Begbie found it partirulaily useful in the eaily
stage of algidity when the patient was young
and could be easily moved about During the
epidomy in Naples in 1884, Higoletti employed
the warm bath lately in the algid stage with
the best results The bath was piopaied with
water at the tempeiature of 100° to 104° K , to
which some liquor ammonite was added Under
this tieatineut the diarrhoea continued, but the
vomiting and hiccup ceased, the pulse unproved,
and the secretion of urine was re-established
This method was also found of service in the
recent epidemy at Hamburg, and ought to be
tried Fu mildei CMSCS, hot, moist linseed
poultices, sufficiently large to cover the whole
abdomen, sides, and lower pait of chest, and
changed Itefoie they begin to get cold, or the
hot pack, along with f notion to the e\ti entities,
should be lesorted to It stimulants ate to be
employed in tins stage they should I*1 used in
great moderation
M uvula.) Gtam/H — Foi lehef oi muscular
ciamps f IK turn with some stimulating liniment
should be employed II this docs not succeed,
a tourniquet placed ON ei the upper pait ot the
limb, so as to constant it, may be tiled The
compression should not, howevei, be continued
too long, but ha\mg been intermitted, it may if
necessaiy be rcsoited to again
To vum up Our efforts must Ixs duected to
stop the diaiihavi in the early stage by astnn-
gents If this fail, or if the patient comes
under tieatinent aftei the disease is developed,
calomel by the mouth and taumc acid enemata
should be employed In the state of collapse,
the waim bath, hot packs, or, in mild cases,
large linseed poultices, with f notion to the
extremities, and a judicious use of stimulants
by the mouth 01 subcutancously, are the most
hopeful means of relief The typhoid symptoms
which often follow cholera aie to be treated on
the ordnmiy prim iples applicable to the special
conditions picscnt
Cholera Infantum. >SVe GASTRO-
INTESTINAL DISORDERS or INI-AWY (Diarthoea),
COLON, DISEASES OF , DIAKLUKLA , FAGJCH
Cholera MorblJS. See CHOLERA
NOSTRAB
Cholera Nostras.
DEFINITION
SYMPTOMS
PATIIOI OM
DIAGNOSIS
PROGNOSIS
TKKATMEN r
125
127
127
12*
128
SYNOMMM — Cholenut Dwith<rat Cholera
MotbiiSi (Jholeane, Spmadic Choleta , DmrtJifa
<fjnd<fmiffue (Fi ), Sptnaihtrhe Chalet a (Cerm )
DJCHMIIOV — An acute, intense inflammation
of the gaslio- intestinal tract, especially of its
mucous membrane, accompanied by copious
\\atuydischaigns from the bo\\ul, and in most
instances introduced bj acts of \ouiiting, simu-
lating in the later stages Asiatic cholera, but
gning no eMdonce of the piesencc ot the
"comma' bacillus
KnoLtxA -- The presence of poisonous bodies,
animate' 01 inanimate, \\itlnn the lumen of the
almientaiy canal supplies the rausatne agent of
choleiaic diaiihuvi, the resulting effects vaiying
with the piecise nature of the poison and the co-
incident environment, both locally and generally
Many agents pioduce symptoms of diarrhoea
physically indistinguishable from one another
The stools in tine choleia, ocea&ionally in enteric
fever and malanal attacks, and those following
aisemcal poisoning and sunstroke, apart from
any specific micro-organisms in them, aie very
sinnlai in character to the ahmc e\acuations of
choleia nostras
In e.ich case the presence of the exciting
cause leads to inflammation of one, 01 all, of
the coats sin rounding the intestine, and fre-
quently oi the stomach also
In choleraic dianhwa the cause may be
oiganismal, 01 bo domed fiom the pioducts of
oiganiain.il metabolism
Choleiaic diaiihoM is, in iact, an inflamma-
tion ot the digest no canal caused by vanous
agents, but in its lesulls simulating Asiatic
choleia moic 01 less closely, absence of the
specific "comma" spnilluin of the latter disease,
and of the symptoms significant of tins organ-
ism's 11101 e intimate and potent influence upon
the tissues and piocesscs of the body, seixing to
distinguish it
The question of greatest mteiest for us is
coiiccined \uth the behaMour and conduct of
the line tonal species which noimally inhabit the
intestinal canal When of good conduct they
seive to contiol the fermentative processes,
brought into being by then o\\n actions, but
regulated by leason of the antagonistic proper-
ties severally displayed Commonly peaceable
and useful, may they not, stimulated by for-
tuitous suiioundings, acquire and exhibit on
occasion a power to do evil ? Encouraged by a
novel environment, affording them abnormal
but moie easily assimilable food - stuffs, may
126
CHOLERA NOSTRAS
they not wax more rapidly m number, and
elaborate more poisonous toxins ? Appendicitis
would appear often to be due to altered charac-
teristics of this kind endowing micro-organisms
in the bowel with harmful tendencies Intes-
tinal dyspepsia and fermentation, enteritis (but
a short step further forward), acute gastro-
entenc inflammation can be initiated by similar
agents in different stages of Airulence The
bacillus coli commums, for example, is a normal
peaceful inhabitant of the Ixnvel , usually assist-
ing in the struggle against saprophytic organ-
isms and to clunk putiefaction, but easily
induced, as it seems, to assume new loles, and,
as circumstances fa\our, to become the active
exciting cause of inflammatory conditions both
m the bowel itself and in the body tissues
Bacteria of this class may be supposed not
only to mcuase m vigoui and numbers moie
markedly in the bowel undci favourable con-
ditions, or to elaboiate moie toxic poisons, but
to behave in the same mannei also if present in
food-stuffs before mgestion, ami those latter, on
gaming the bo\\cl, may bo able to work evil
Whenevorg,i8tio-intestinalctttarihoceurs,8ome
predisposing cause may be picdicated \\ ith surety
The exciting cause may come from without, 01
may be generated within , m either case contribu-
tory conditions have nearly al\vays preceded
Insufficient food, 01 food of unsuitable charac-
ters, lack of fresh an, weakened physical and
mental poweis, eyposurc to extremes of tempeia-
ture, particulaily if mdoois, with overcrowded
and non-xentilated looms, render the chance of
an attack more probable and more severe
The most potent contiibutory cause of attacks
of choleraic diarrhoea in babes and sucklings
arises fiom the well-mgh ineradicable belief
implanted in the popular mind, that the young
were never intended to breath the fresh an ot
heaven except dunng the compai ativcly buef
ponods when they aie "taken out" Unclean
Dottles and cups, impute milk, foods unsuited
for them at then age, would often prove innocu-
ous, for the body m healthy cm. umstances is
capable of much, if only the child weie allowed
enough oxygen Ot course, too little food is
also a common predisposing cause, and when
conjoined to dose apaitments almost eeitamly
fails to permit of a successful stiuggle against
poisons ingested No wonder that in enfeebled,
marasmic childien, hot -house bred, but with
less fresh air than is supplied to hot -house
plants, ataived of oxygen, the bacteria find a
congenial soil in \\hich to increase and multiply,
little hindrance heie to their running amok
Milk that is tainted, so common during summer,
especially if the supply is dehvciod but once in
the day, too largo a quantity of it given at one
time, allowing many of the bacteria in it to
escape the antiseptic action of the stomach's
secretion, a dietary composed of "bites of what-
ever IB going," want of legulation of the action
of the bowels, constipation relieved at intervals
by strong purgatives, — all are active or acces-
sory causes in infants
It is probable, also, that poisons absorbed
into the en dilatory fluids of the body, especially
those manufactured by abnormal intestinal
piocesses, when in larger amount than can be
dealt with by the Iner, in virtue of its protec-
tive propei ties, may occasion an attack of
choleraic diairhcca by a geneial m addition to
a moie local action exercised on the neive end-
ings and hbiils in the wall of the gut during
then tiansit fiom bowel to vessel
The actual and tiue cause of choleraic
diarrhoea is almost always to be found in the
presence oi poisonous pioducts ot the meta-
bolism of living forms, and olten of the living
forms themselves (apablo of elaborating them
Under ordmaiy cncumstancos many of the
active agents and some of the poisonous pro-
ducts are unable, by raison ot a loss activity, a
iiioio rapid and thorough noutialisation, to do
much haim, but at othei times they may be
so generated, nourished, manuied, and en-
vironed as to possess extraoidnuiy powers of
de\ elopmcnt and increase Instances ol choleraic
diarihuu caused by mineral poisons, and many
othois ol the moie common chemical substances,
fall to be discussed moie pioperly under " Food
Poisoning," " Toxicology "
The victims of choleraic dianha>a, if adults,
suftvi, as a rule, because of their own indis-
cretion , from the folly ot those put over them,
if in < hildhood
The attacks of the disease are supposed to be
moie apt to occur under nieteorologic.il con-
ditions favouring heat by day with dispiopor-
tionate cold by night, oi when the an is warm
and moist Hut these conditions can have but
little cflect on the mode or season of attack
unless accompanying mgiess ot some poisonous
agent or substance And even then those who
avoid the inhalation ot re-exhaled, impoverished
air, nor sleep in the same, long fasts, sluggish
action of the bowel, and lack of muscular exer-
tion, seldom are unable to overcome and inhibit
the agents introduced into their bowel (unless if
m most unusual quantities), which in those who
live conversely would be almost certain to find
.1 fertile soil unprotected and uncarod for Im-
pure water, tainted meat, animal ptomaines are
more commonly met with in hot weather, in
fact, all bacterial lite is more active
SYMPTOMS — In Infants — The little victim to
one ot these attacks is in all probability appar-
ently in a normal state of health up to the
actual onset of the symptoms Of a sudden the
contents of the stomach are expelled, generally
soon after a meal, in an undigested state, and
almost at the same time a more or less fluid
discharge takes place from the bowel. The dis-
charge is acid, often green or green-yellowish in
colour, and containing lumps of undigested
CHOLERA NOSTRAS
127
food In the majority of cases the vomiting
soon ceases, but sometimes the stomach may
continue irritable throughout There may be
as many as from twenty to thirty motions dur-
ing the first twenty-four hours, the later dis-
charges becoming colourless, almost odourless,
and in fact similar to those of tiuo cholera
The child suffers fiom thirst, frequently most
intense, horn aMommal pain, as the dialing
of the legs up against the al>d onion and crying
show , from local pain lound the anus, imitated
by the acrid stools, he becomes prostrated,
wizened m look , the body tempeiatme falls
below noimal, the pulse but flickers and il the
diarrhoea persists, muscular tramps, followed
soon bygeneial convulsions, set in, death closing
the scene In seveio cases a previously strong,
woll-nou ushed child will lose \\ithin but a few
hours all hw healthy run es and plumpness, to
show in his appearance all the signs of extreme
marasmus
At any stage of the attack, however, the
symptoms may halt and shoitly leccde, in
even seemingly hopeless cases lecovery may
result (we "(Jastro-Intestmal Disorder")
Adults — Few piemomtoiy symptoms assert
themselves Severe purging, with 01 \\ithout
precedent emesis or gastric nausea, but always
accompanied with paioxysm-il abdominal pains,
fioqiiently of a most agonising chaiacter, the
passage hist of liquid twees, dark sometimes in
colour, light hue 1 as a rule, nutating ami pain-
ing the anal MI i tare, of mote 01 Icsss foul odour,
becoming more and more liquid, with less and
less smell and colour, moie ficquent and copious,
in time indistinguishable fiom the rice -water
stools oi tine cholcia, lead to the sharpened
features, the cold, clammy goose-skin, the
intense thust, the lessened urine, the ciamps
and prostration significant of excessive absti ac-
tion of flu id and seium from the oigamsm
The prostration, the cold skin, and the actual
lowering of body-temperature which may occur
are undoubtedly as often caused by reflex action
through the nervous centres from sin irritation
of the local terminations of intestinal nerves .is
through actual loss of fluid, while as the result-
ant eftoct is to withdraw blood from the skin to
supply the inflamed intestinal tissues, the dis-
chaige of fluid into the lumen of the gut is
facilitated
Should the attack proceed to a fatal ending,
the skin becomes cold and livid, the face more
pinched, the muscular spasms more general,
although towards the end they are replaced by a
comatose, quiet state , or again, the mind may
almost to the last retain its full consciousness
During an attack the urine is always scanty , in
fatal cases it may bo completely suppressed for
some time before death
If the attack arise from mgestion of preformed
ptomaines, violently poisonous and irritative m
character, the time which elapses between their
mgestion and the onset of the symptoms vanes
directly with the character of the meal taken
which included them, its amount, and the
strength of tho gastric juice encountered If
the stomach bo empty, or nearly so, and the
poisonous agent taken in a liquid, the symptoms
occur rapidly , if in solid loi m, a longer time
elapses, while if taken along with all the com-
ponents of a full meal, the onset of diarrhoea
may bo delated until eighteen or twenty -four
hours have passed
if the cause be due to organised forms, the
appearance* of symptoms is usually longer de-
layed, varj ing direc tlj v\ ith the v irulence of the
bacterial tvpeand the facilities afforded it for
its growth
One form of a< ute diairhcra, in many instances
reaching choleraic intensity, is of interest, al-
though of doubtful etiology It is every now
and then met with in large institutions, especi-
ally in the w liter's experience in boarding
schools From no discoverable cause a number,
perhaps e\en the majority, of the inmates will
be attacked almost simultaneously with acute
diarrhtra Seldom serious, much the larger
propoition of those attacked recover speedily ,
a niinoi ity, how ov ei , may suffer seven ely From
what can such an attack arise? Not from food,
for all cat the same*, and all do not suffer
I'AIHOIXXJY — The pathological conditions are
akin to thoHC of acute gastro-cntcritis The
mucous lining of the gastro-mtestmal wall is
acutely inflamed over a more or less extcnsrve
area If the initant cause is very powerful,
the inflamuutoiy changes may spread to the
other coats of the bowel wall
Investigation of the watery stools shows them
to be almost entirely composed of puie serum,
drained by the intestinal glands from the blood
From them various forms of bacteria can be
grown, and ptomaines may be isolated by appro-
priate methods The bacillus coh comimmis is
constantly, well-nigh invariably, to be found
DIAGNOSIS — The most important point in
the diagnosis of choleraic diarrhoea lies in its
differentiation from Asiatic cholera This point
settled, it is of little moment to be able to
distinguish choleraic diarrhoea due to one special
form of pd'soii from that caused by another ,
the symptoms are practically identical, the
treatment the same
A history of previous contact with infection,
early onset of collapse, of loss of voice and
enfeebled pulse, and the detection of the comma
bacillus m the stools suffice to indicate the
presence of true cholera
Occasionally purely nervous diarrhcorc attacks
closely simulate choleraic diarrhoea, but here
a history of former illnesses of the same type,
of some nerve disturbance, the comparatively
slight discomfort or pain experienced, the
character of the dejecta, less offensive and maybe
watery from the commencement, and the slower
128
CHOLERA NOSTBAS
onset of signs of exhaustion, serve to point a
difference.
The occurrence of choleraic diairhcca during
the progress of enteric fever is infrequent, and
can scarcely be mistaken foi other than a com-
plication of the primary disease, except when
accompanying an ambulatory unsuspected case
The liquid stools common in intestinal fermen-
tative dyspepsia chiefly c.ill foi evaluation in
the morning hours, <iro intensely foetid and
fojculent, and accompanied by much flatulence
The symptoms attendant on (ohtis, mucous
and membranous, and the distinctive characters
of the motions in these conditions, as well as
the differential signs of dysentery and dysenteric
diarrhoea, are treated of under their seveial
headings
PROGNOSIS — Unless among infants, old people
with weakened power of resistant e or with feeble
hearts, or in chronic imahds of little vitality,
choleiaic diarihoja,when mdependentof ptomaine
poisoning, is seldom fatal, although seeming on
many occasions to nearly iorebode death In
infants fed improperly, housed in badly ventilated
or un ventilated rooms, it pioves very fatal In
adults, when uncomplicated, and whoie pioper
chances for treatment aio obtainable, it rarely
causes death, unless it be the lesult of poisoning
by ptomaines taken with the food in sufficient
quantity to overpower all means of successful
resistance 01 treatment
TREATMENT — Staivation is the best line of
tioatmcnt in both infantile and adult choleraic
diarrhooa, cold or iced water, and in adults,
aerated watei, if desired , if well tolerated, a
little milk and lime watci may be guen, test
the afiectcd parts In such cases one or even
two days may easily pass without nourishment
being taken In infants, unless the diarrhoea
ceases eaily, tins should be a constant rule,
ignore the protests of parents 01 relatives In
adults when a desire for food returns, apart from
the simple craving for fluids, milk diet may be
safely begun
In adults the less medicine given the better
Cold or iced water, hot-water bottles to the feet
and legs, hot poultices, with or without mustard,
over the abdomen, and plenty of ficsh an
generally sufhco to arrest the symptoms
The administration of opium 01 morphma is of
questionable piopncty The poison in the
alimentary tract merits lenioval rather than
detention, but it the pain be great, and the
reflex nervous piostiation pronounced, free use
of opium will help to remove any chance of
immediate collapse If the patient be in a less
prostrate state, the application of warmth, a
small dose of calomel — large doses ot calomel
are dangeious, while small amounts are better
fitted to act antiscptically, — and half-ounce or
even ounce doses of whisky or brandy, often
arrest the symptoms If painful cramps super-
vene, etherisation is advisable, indeed the
calmative effect of an anaesthetic upon the whole
nervous system, and the relief obtained from
the pain of cramp and from the local abdominal
pain, suggest that an earlier employment of an
anesthetic in such cases might prove of gieat
service If seen early, administration of castor
oil and laudanum together act well
Should the stomach bo restive and i eject the
stimulants oideied, or the patient continue to
retch, dilute hydrocyanic acid mav bo given, or
tcaspoonfuls of brandy and watei, in which one
diaclim of the spnit is added to t\vo or three
ounces of watei, the dose to be repeated every
few minutes if vomiting threaten Should the
dial i hoja be unchecked by such measures, the
sedative poweis of opium 01 nioipluna may be
called upon The most efficacious method
undoubtedly lies in the use of moiphma supposi-
tories
A day 01 t\vo after the active symptoms have
abated, especially if they haAe been anested by
the use of opium preparations, a full dose ot castor
oil may be given with safety to clear out all
that remains in the bowel
The geneial indications for treatment may be
summed up in a tew woids If the patient
appears to lie strong enough to bear it, icuiovo
the exciting cause , if collapsed, and in danger
from persisting exhausting discharges from the
bowel, stimulate, and introduce morphma m a
suppository or under the skin, in all cases
apply warmth to the abdomen and the lower
limbs, stop all food by the mouth, — in adults
milk may be allowed, — inculcate test, and secuie
the picscnce of fresh air
Cholerine. — This name (cholerine) is
sometimes regaided as a synonym of (hole* a
nortta* (qv\ sometimes as a term for a form
of influenza with intestinal symptoms, or for the
milder varieties of diarrhoea which are common
during the prevalence of epidemic cholera
Cholesteatoma.- A cystic tumour,
with a pearl-like appearance, containing white
fat and cholestcrme crystals, and sometimes
hairs See BRAIN, TUMOURS OF (Moibid Ana-
tomy), EAR, APFKTIOKH o* TYMPANIC MEM-
BRANE, EAR, MIDDLE, CHUOMC SUPPURATION
(Cholesteatoma)
Cholesteraamla.— A group of symp-
toms (jaundice, irritability, and other nervous
symptoms) believed to bo due to the presence in
the blood of cholesterine See JALNDICK
CtlOleSterlne.— In chemical composi-
tion cholesterine is an alcohol (C20H48OH), but
it icsembles the fats, being soluble in alcohol or
ether , its crystals are square with a notch at
one coiner " Lanolme," or Adeps Lance
Hydtomti, is cholestcrme fat which has absorbed
much water. See EXPECTORATION (Ciystah);
EfflCES (Chemical Examination) , FLUIDS, EXAM-
CHOLESTERINE
129
INATION OF PATHOLOGICAL (Chemical Analysis),
GALL- BLADDER AND BILE- DUCTS, DISEASES OF
(Cholelithiasis) • KIDNEY, SURGICAL AFFECTIONS
OF (Cysts) , LIVHU, PHYSIOLOGY OF (Bile Forma-
tion) , PHYSIOLOGY , SKIN, ANATOMY AND PHYSIO-
LOGY (tiectetion, Sweat, Mum) , URINE, PATHO-
LOGICAL CHANGES IN (Cftoletfenne, Calculi)
CholOSterltlS. — A morbid sUte ot the
vitreous or aqueous humour in \thith cholcs-
tenne ciystals (separated from the lens) are
found floating therein
ChollC Acid.— Choho or cholahc acid
(C24H400B), present m the bile m the foim of
taurocholates and glycocholates Kee PHYSIO-
LOGY (Bile)
Chollne. An alkaloid (C^H^NO,) found
in bile, in nerve tissue (m lecithin), and in
fungi , it is toxic, resembling muscanne m its
action, and has been regarded as the cause of
epileptic seizures tiee PHYSIOLOGY, TUB TISSUES
(JTftve)
CtlOlOgen. — A pteparation used in cases
of obstruction of the bile-duct, diabetes melhtus,
etc
CholOpOleslS. — The formation of bile
See Pii\hioioa\, FOOD AND DIOKVIION (Rile)
CholuHa. — The piesenoe ot bile 01 its
elements (? <) pigment) m the urine (q v ),
detectable by Gmelm's test (pUy of colour)
#«• JAUNDICE
Chondr-. — In compound \voids chon-dt-
and ihoiulto- mean relating to cartilage, as is
exemplified in such ^oids as thondtfilyui (pain
in a caitilage), <hondtejuitthio»i^ (displacement
of an aiticulai caitilage), ihondujnation (trans-
formation into cai tilago), (hoitdt tti s (inflammation
of cartilage), <1iondiobla<*t (a caitilage- forming
cell), chondiotlatt (a caitilage -absorbing cell),
c/ion(lto-ctu)uuni (the early stage of cranial
development), (.Jiomhodmly*n (decomposition of
cartilage), chonfttogennti (foi niation of cartilage),
t/iondt omalacia (w)ftemng of caitilage), ctwiulio-
phyte (an outgiouth from, or tumour of, carti-
lage), and cftoiidtoMttconui (a vanety of saicoma)
Chondro - arthritis. — Gummatous
ulceration causing lemo'val of the articular end
of a bone, and leaving but a thin membrane
(representing the cartilage) over the ulcerated
surface See SYPHILIS (Teitmry, Bones and
Joints)
Chondrodystrophla Foetal 1 8.
See ACHONDROPLASIA , CRETINISM , PREGNANCY,
INTRA-UTERINE DISEASES (Fatal Hone Di*ea8est
Osteogenesis Imperfecta)
Chondrotna. — A cartilaginous tumour
See BONE, DISEASES OF (Tumours, Chondtoma) ,
HAND (Turnouts), HIP- JOINT, DISEASES OF
(Tumours) ; NECK, REGION OF (Solid Tumours) ,
PAROTID GLAND, DISORDERS OF (Tumours) ,
TUMOURS (Connective Tissue Tumours, Chondro-
mata)
Chopart'8 Operation. See AMPUTA-
TIONS (Ankle-Joint).
Chorda. — A cord or 'cord-like structure,
such as the notochord (cJtorda dot tali s), umbili-
cal cord (cJunda umbilimlts), the chorda tympani,
and the chwdce tendincce
Chordee. — A painful erection of the
perns, during which it is bent or twisted down-
wards See PEVIS, SURGICAL AFFECTIONS OF
(Choi dee), UKEIIIHA, DISEASES OF (Gonorr/wea
in, Men)
Chord It 18. --Inflammation of a cord (e g
\ocal coid) or cord-like structure
Chordoma. — A tumour consisting of
notochoidal tissue
Chorea.
El IOLOGY
SYMPTOMS
COMPLICATIONS
PROGNOSIS
PATHOLOGY
DIAGNOSIS
TRKAI ME^ r
HEREDITARY ADULT CHOREA
CHRONIC PROGRESM\K CHOREA
ELECTRICAL CHOREA
CHOREA MAJOR
CHOREA GRAVIDARUM
130
130
132
133
133
134
134
135
136
136
136
137
See alto AiiihTosis (Diagnosis) , BRAIN,
AFIKCTIONH OF BLOOD-VESSELS (Pont-Jtemiplegtc
Chotea) , CATALEPSY, CFRFHELLUM, AFFECTIONS
OF (Chtnufoim Mowmivt*) t CIIILDHEN, CLINI-
CAL EXAMINAHON (Ntivous System) , HYSTERIA
(IJyvtetual Choiea) , H\PNOTISM (in the Treat-
nunt ofCh(»e<i), INSANITY, ETIOLOGY OF (Auto-
tojitc Ayencit*), LABOUR, OPERATIONS (Induc-
tion), LAR\NK, CONGFNITAL LAKYNGKAL SIRIDOR,
MLASLES (Se^mla?) , MIND, EDUCATION OF TUB,
(Hysteucal Childien), NOSE, POST-NASAL ADF-
NOID (GROWTHS, PARALYSIS (Cetehal Diplegiri) ,
PUBERTY (Dit>tin hi iicei of H&tlth) , PREGNANCY,
AFFECTIONS AND COMPI ICATIONS (Neivont Sys-
tem, Choita) , HHEUMAIISM, ACUTE (Netvouv
Symptom*), RHEUMATISM IN CHILDREN (Choiea),
SPASM (Pniantyoilonus Multiplex, Diagnosis),
SKIN, PK.MKVTARY AI-FECFIONS OK (tn C/totea)
THE name "chorea" IMS unfoitunately been
applied to a number of entirely different com-
plaints, the common featuie in all "choreic"
diseases being tho occurrence of involuntary,
11 regular muscular movements
COMMON CHOSEN
(Chorea Minoi , Sydenham's Chorea , St Vitus's
9
130
CHOREA
Dance) consists m a group of characteristic
symptoms of aubacute onset! and chiefly occur-
ring m children.
ETIOLOGY —^.—Chorea is essentially a dis-
ease of childhood and adolescence, the vast
majority of cases occurring between the ages of
five and fifteen years Aftei fifteen years of
age chorea is much less common as a primary
attack, although second and third attacks are
by no means uncommon after puberty After
the age of twenty chorea, becomes still loss fre-
quent, although no age is exempt, and the disease
may develop even up to an advanced age, as in
one form of chorea sem/ts
Sex. — The female sex is much more liable to
this disease than the male, the average propor-
tion being three girls to one boy After the
age of fifteen there is a still greater preponder-
ance of female patients
HereJitaiy Influence — A family diathesis
towards rheumatism is veiy common, and should
be inquired for in every case of chorea In a
consideiable proportion of cases a family histoiy
of nervous diseases can also be obtained
Rheumatism and Etulot<i)<littt — Expeiionce
shows that a very largo number of cases occur
in patients \vho have had articulai rheumatism
Many patients develop ihoumatism in the course
of an attack of choiea or at a subsequent period
Also many cases of chorea aie preceded or fol-
lowed by endocaiditis The endocarditis is
sometimes discovered for the first tune dm ing
the course of the choiea, and it is laio to hud a
patient with a second or thud attack of chorea
in whom the cardiac sounds are normal
In a recent series of forty one consecutive
cases of chorea, in t \\elve of them (including a
primigravida) there was a histoiy of previous
rheumatic fever , another patient developed pain
and swelling in both wrist- joints whilst under
observation, within a week aftei the onset of the
chorea, whilst anothei primigravida, who had
previously had two attacks of chorea, developed
pain and swelling in one knee-joint a fortnight
after the commencement of her attack of chorea
gravidarum Of the icmaining twenty-seven
cases, fifteen had a strong family histoiy of
rheumatic fever, whilst in the remaining twelve
there was no history of iheumatic fever either m
the patient or in the patient's near relations
Yet out of those twelve no fewer than five had
mitral regurgitation, one had mitral stenosis
which ultimately proved fatal, and only six had
no valvular affection of the heart
Scarlet fever with arthritic manifestations is
recorded in a few cases to have been a direct
antecedent of chorea
JFnyht, emotton, traumahsm, or some variety
of shock to the nervous system is a fairly com-
mon antecedent to an attack of chorea, although
the majoiity of cases develop without such an
exciting cause Still a history of some fright or
shock is obtained in from 20 to 30 per cent of
cases. Mental emotion as an alleged exciting
cause is more common m adolescents, from the
age of sixteen upwards, than m childhood. But
the study of a number of cases of chorea attri-
buted to emotion shows that the vast majoiity
of them occur in constitutions which are already
rheumatic Moreover, the history of mental
shock is often an indefinite one, and early chorcic
symptoms are often piosent before the advent
of the emotion which exaggerated them In the
above series of foity-one cases, fifteen gave a
history of some flight or mental shock, but of
those fifteen only one was fieo from evidences
of rheumatism, twelve of the othois having either
had iheumatic fever or initial disease, and the
remaining two having a veiy stiong family
histoiy of iheumatic fever
It used to be thought that chorea may spiead
ftom one patient to another by imitation
Small epidemics of choreiform movements, such
as have now and then been iccoided in girls'
boarding-schools, aio really h^stciical in natuie
and not truly choioic A pinnarily choreic
child, hovsever, may have a iclapse of tiuo
chorea from the excitement of seeing anothei
patient with a similar affection
The presence of wot MI m the intestinal (anal
has been believed hy some to cause the dise.ise
11 ceitam cases by reflex nritation But in the
above senes of cases the only case of choiea in
a child with t.ipe-woim occuiied in a girl who
had previously had an attack of iheumatic
fevei
Ptegnancy undoubtedly acts as an exciting
cause m certain patients, the disease developing
in the eatly months of gestation, usually horn
the third to the fifth month, cithci in pieviously
healthy patients, 01 moie frequently in cases
with a previous history of rheumatism 01 of
actual chorea Young prmiigiavidw are chiefly
so affected, frequently unmairied gnls The
connection between the choiea and the pieg-
nancy is so close a one that when the pregnancy
comes to an end, cither m a normal manner or
byaboition, the chorea ceases Frequently the
disease rocuis with succeeding pregnancies (vide
" Chorea Gravidarum ")
SYMPTOMS —The disease is gradual in onset,
usually taking a day or two to develop suffi-
ciently to call attention to the presence of any
abnormality The patient is otten fretful and
more irritable than usual , then restless, wiigg-
Img movements are observed in the limbs, face,
and trunk The child at school cannot sit still,
and the teacher complains that the patient's
handwriting is clumsy and untidy Often the
patient drops things suddenly out of the hand
Sometimes this condition is not recognised as
being really due to disease, since a degree of
motor restlessness is present in many children
during mental embarrassment 01 other emotion
The choreic child is often considered at first to
be merely badly behaved, but as the symptoms
CHOREA
131
develop, it becomes evident that there are some
underlying diseased conditions.
In a typical, fully developed case of chorea the
symptoms may be classified into various groups,
viz (a) irregular, involuntary movements , (6)
incoordmation on attempted voluntary move-
ments , (c) weakness of the affected limbs , (d)
a van able amount of psychical disturbance
The irregular, involuntary movements are
quite characteristic They are of a twisting,
wriggling, tossing typo, quite irregular in time,
and constantly vaiymg in character and degree
The patient cannot stand or sit still, but is in a
state of continual motor restlessness — "fidget-
ing " The movements are usually first noticed
in the arm or face, the lojrs, as a rule, being less
affected The shoulder may bo suddenly
shrugged, tho arm abducted or adducted, the
elbow flexed or extended, the hand pronated or
supmated, the fingers spicad out, flexed, or
extended, and these sudden n regular move-
ments aie often combined in a complex, confused
fashion
Similar movements are also seen in the face
Tho brow may be suddenly wrinkled, or briet
grimaces may be made, the mouth being dra\\n
to one side, the lo\ver lip ovoitcd, the mouth
pursed up, the uppoi teeth exposed, 01 the cycn
screw ed up The oc ular in uscles also pai ticipate
the patient does not fix objects steadily, but looks
restlessly luthei and thithei, and may now and
then squint momentarily Tho ja\v,s may open
and shut iriegutaily, the tongue may bo i oiled
about m vanous dnections, and not niFiequeiitly
it is bitten by a sudden involuntary snap oi the
teeth Sometimes tho soft palate is soon to
move irregularly up and down The move-
ments of the rnuseles in and around the mouth
may produce peculiar sucking, smacking, or
slobbering noises
Tho trunk is often rotated to one side 01 the
othei, and tho head suddenly tuincd in various
directions Respuation is frequently jerky and
irregular Tho action of the diaphragm is often
overshadowed by that of the mteicostals and of
the extra muscles of tospiration Sometimes
the diaphragm and intercostals contract alter-
nately instead of synchionously In a fow case*-
the laryngoal muscles are affected, so that jerky
laryngeal noises or gioans are produced
Choreic movements in tho legs are usually of
a much less ( oiuphcated type than in the upper
extremities The patient cannot stand placidly,
sometimes one foot is moved, sometimes the
other Walking is only impaired in severe
cases The knees may suddenly give way during
progression, or the movements of the legs may be
BO violent that tho patient is unable even to stand
The choroic movements vary in degree in
different cases, from the slightest restlessness
of the fingers to the wildest and most violent,
irregular movements of all the voluntary muscles
of the body. The affected joints are impetuously
flexed, extended, rotated, or circumducted, and
in severe cases the limbs and trunk may be
thrown about so violently that the patient may
fall out of bed, or may bruise or cut the bony
prominences of the liead, trunk, or limbs by
throwing them against surrounding objects
The movements usually commence in tho
hand, spreading later to 'the face, trunk, and
leg They generally ailoct one sido of the body
earlier and more severely than tho other Often
they remain confined entnely to ono side (hrniv-
ctiorea) In a fow cases they migrate completely
from one side to the othei As a rule, in right-
handed patients tho loft side is more commonly
affected than the right , but this is not in van-
ably the caae Sometimes tho movements
afH pt both Hid«'s with equal intensity
Voluntary movements arc more or less inter
fered with, \\hen involuntary nhoreic move-
ments are going on The patient executes
voluntary movements hastily and spasmodically
as if attempting to sei/o an instant \vhcn choreic
movements are absent Sometimes, ho\\evor,
voluntary movements aie almost steady, whilst
involuntary movements aio well marked, but
more commonly choreic movements aio inci cased
by voluntary movement A good test foi
slight cases of choica is to make tho patient
hold up both hands foi a few seconds above his
head with tho fingers outsti etched This usually
succeeds in bringing out a fow n regular, wrigg-
ling movements of the fingers on the affected
side Or make the c hoieic patient squeeze one's
hand, and tho grasp is perceived to be sudden,
spasmodic, and ill-sustained If the grasps bo
compared on tho two Hides in a case of hemi-
choroa, it will be found that the grasp on the
choreic side, although moro sudden, is yet
actually weaker than on tho unaffected side
Sometimes when picking up objects tho patient
makes a sudden dash for the article and often
diops it after seeming it Sometimes, again,
the patient has a difficulty in letting go an
object when he wishes to do so Thus in feeding
himself ho often drops his cup, and scatters his
food about tho tablo with his knife and fork
In the lower limbs, in addition to the in-
voluntary movements already described, the
gait may be peculiaily altered The knees may
suddenly give way during walking, causing the
patient to fall
When the tongue is protruded it is shot out
suddenly and pulled in again with a jork
Articulation is often jerky and indistinct
Words arc shot out, suddenly cut short, or
mteirupted by the iriegular respiratory move-
ments In bad cases the speech may be quite
unintelligible, or the patient may speak only m
whispeis, 01 may even absolutely refuse to speak
at all for days or woeks In the latter instance
there is a superadded psychical element present
Severe affection of the lips, tongue, and
pharynx may cause inco-ordination of swallow-
132
CHOREA
mg, and the general nutrition may thereby be
gravely affected
The motor unrest is greatly increased by
emotional states The excitement of a medical
examination often renders the movements much
more violent Scolding the patient by teachers
or parents only makes the child more restless
Sometimes the pitient sleeps badly As a rule,
duiiug sleep the choieic movements entirely
cease , but m very lare cases exactly the reverse
condition is found (chotea noctuma), in which
the movements aie greatest during sleep, dis-
appearing almost completely when the patient
is awake
A considerable degree of muscular weakness
is common in chorea, and in some cases this
may bo so sevcic that the patient is unable to
raise a limb from the bed, although slight rest-
loss movements are seen going on irregularly in
the weakened limbs But the patient can
always execute voluntary movements, however
feebly, at all joints in the apparently paralysed
limbs There is never complete paralysis of
any group of muscles Such cases, wheie the
weakness is out of all proportion to the choieic
movements, have been termed " paralytic
chorea," and in many of them the ehoreic
movements aic only elicited on attempted
voluntary movement In some CUSPS musculai
paresis is the earliest symptom of the disease
The patient's relations notice that the child
uses one arm less than the other, and finally
that he does riot use it at all AH the disease
recovers the paresis fades, and the ehoreic
movements become more evident
The muscles remain noimal in volume
Their electrical excitability is sometimes in-
creased on the affected side, both to the con-
tinuous curient and to induction shocks
Sensory abnormalities aie more frequent in
chorea than it is geueially supposed It is
true that choieic patients do not usually com-
plain of pain, numbness, or any abnoimal
feeling, but if the cutaneous sensibility be catc-
fully tested in e\ery case, it will be found that
a const dei able piopoition of patients exhibit a
slight dcgiee oi blunting of sensation on one
side of the body This was so in ten cases out
of forty-one in the above series Such hemi-
amcsthesia, when present, is always 011 that side
of the body on which the choieic movements
are most marked Sometimes the visual fields
are concentrically conti acted, and the acuity
of \ision, smell, taste, and hearing may be
diminished on the piepondoratmgly choieic
side, with or without slight hemi-anccsthesia to
touch or pain Such affection of the special
senses is strongly suggestive of a hysterical
element super-added to the chorea, but the
frequency of hemi-aiitesthesia is very striking
The heim-aiuesthebia of chorea is very slight
in degree, and can only bo detected by careful
comparison of conespondmg points on opposite
sides of the body. When this is tned a con-
siderable proportion of patients will be found
to perceive light touches and pricks more
acutely on one sido than on the other, and the
boundary of this area of blunted sensibility will
always be found to lie m the middle line of the
body Sometimes the trunk and limbs are
alone involved m the henn-anajsthesia, the face
and scalp escaping
As to the reflexes, the skm-refloxes aro occa-
sionally diminished on the hemi-anvosthetic side
The deep reflexes may be normal, but sometimes
they arc difficult to elicit In other cases we
may find the " ehoreic knee-jerk " This differs
from the healthy knee-jeik m the fact that
when the patellai tendon is tapped, instead of
the normal busk contraction of the quadiiceps
extcnsoi, followed at once by a sudden relaxa-
tion, the knee in such ehoreic cases is suddenly
extended to its full extent and remains so
toi a second or t\\o, the foot and toes mean-
while exhibiting irregular ehoreic movements
Ordinarily the spli meters are normal, except in
^ery bad cases when extreme mental dulness
causes incontinence of urine and f.eccs
In chorea the optic discs are noimal In
raic instances slight optic neuritis has been
observed This is probably not referable to the
chorea itself, but due to some other com omitant
cause The pupils are often dilated, but they
react normally The tempeiature is normal,
except in very seveie eases, when it may use
In the majority of cases a psychical element is
present This may be tnwal in degree, merely
amounting to a certain irritability oi temper or
a tendency to ciy or to giggle on slight pi evoca-
tion. Sometimes, however, there is impairment
of memory and distinct mental dulnesH The
mental element may be quite out of proportion
to the seventy of the other symptoms Mental
affection is mote common in adolescents than m
young children It usually takes the form of
depression Hallucinations may develop with
delirium, and the patient may (kiss into a state
of violent maniacal excitement This maniacal
form (chorea uisanienn) reaches its maximum
intensity at the acme of the chorea It may
last several weeks, and gcncially passes ulti-
mately into a condition of mental apathy m
which the patient lies in bed like a log, refuses
food, and passes both urine and faeces into the
bed As the patient slowly rccoveis, there is
often a transient stage of mild delirium with
"peisistent ideas" Severe mental symptoms
aro more common in the chorea of pi egnaiicy than
in any other variety of chorea The ultimate
prognosis, howevei, as a rule is good, most
cases of ehoreic insanity recover completely
The urine in choiea contains an excessive
amount of urea, of phosphates, and sometimes
also of htcmatoporphynn
COMPLICATIONS — Of these the most important
is endocarditis, which occurs so frequently that
CHOREA
133
it may almost be considered as part of the
disease Choroic endocarditis chiefly affect*
the mitral orifice and is usually of the simple
type The heart frequently recoveis completely
and its bruits cntnely disappear Sometimes,
however, the \ .lives may remain pcimanontly
damaged Ulceiative endocarditis with em
bohsm is rare
Acute aiticular iheumatism may precede,
accompany, 01 follow an attack of chorea
When occumng simultaneously with choiea, it
is usually mild in type, evidenced chiefly by
joint paniH and moderate pyicxia, \\ith little 01
no joint spelling to be made out on objcctnc
examination
Some choreic children have characteristic
"subcutaneous ihcumatic nodules," vaiying
from the si/e of a pea downward s to that
of a. sago -gi am They aie distnbuted most
commonly along the subcutaneous borders of
the ulna and tibia, also aiound the elbow, knee,
t'nd ankle joints, and along various tendons
around the w lists and ankles Sometimes
these nodules are only discoverable dm ing
the attack of chorea Kiythema nodosum is
sometimes piesent A painful eontracture of
the palmai fascia may .ilso occui during choiea,
dealing up under anti-iheumatic tieatmcnt
Cases of chorea \\ith intense mental symptoms
have ahe.uly been refened to Such maniacal
cases ouui chiefly in adults, and especially in
the piegnant state
Epilepsy as a complication is \eiy lare
Hysteria may complicate choiea, and h}stciical
movements may sometimes simulate chorea,
but the practised obseivc-i h«is usually little
dithculty in iccognising the* existence of a
hysterical element when piesent Hysteiical
movements are usually somewhat difteicnt in
typo horn those of tine choiea, the^ are often
sudden and shock -like, and tend to bo moic
rhythmical than in true chorea
DURATION — The duration of an attack of
choiea is veiy \aiiable The more seveio the
attack, the longer will be its probable duiation
The average duration is from two to Unco
months, but an attack may cleai up in two 01
three weeks, or it may last six months or longer
Only in exceptional cases does chorea peisist
continuously ioi a year or more
As a i ulc, the older the patient is w hen first
affected by choiea, the longer is the duration of
the attack likely to be
Chorea is a disease which is very prone to
recur One or two relapses are common, and
as many as nine relapses ha\o been recorded
The mteivals between two successive attacks
vary fiom a few weeks to several years, the
average interval is about 0110 year In some
cases the patient has an attack of chorea
regularly at a certain season of the year for
several successive years, but as a rule the
attacks recur at quite irregular intervals
Relapses are often slighter in severity than the
primary attack, but the reverse is sometimes
the case
PROGNOSIS — In most cases recovery is com-
plete, the incc-ordmation gradually ceases and
at last the involuntary movements fade a\vay
Serious cases are those in which the movements
are of extreme Molencc, and in whirh insomnia,
delirium, and lapid emaciation supervene Those
may end fatally from exhaustion Sometimes
death results horn rheumatic fever with hyper-
pyrexia, or from cardi.ic failure secondaiy to
\alvular disease Injuries to the skin produced
by the* Molence of the choreic movements may
icsult m intractable sores, and the patient may
die fiom pvft'imc infection
In the common chorea of childhood the
danger to life is but slight, the average mor-
tality being less than thieo per cent Most of
the fatal cases aie fust attacks , death from
a recurience is r.uc Chorea occurring for the
hist time at 01 aftei puberty is much more
dangeious, snue seven* heart-lesions aie moie
fiequent than in the choiea of childhood
Choiea in picgnancy is still more senous,
neail} twenty -tnc per cent of cases proving
fatal In such cases the choieic movements
are usually very violent, ment.il complications
are common, and se\ere endocaiditis is relatively
fiequent Many case's aboit, and in the patient's
cachectic state aboition or e\on normal laboiu
is dangeious
In oxtiemely laie cases jmenilo chorea may
peisist as a peimanent c hi omc disease, with or
without slight remissions, in spite of all 1 1 eat-
in ent This form of chorea is commoner in
males than in females, and seems to t>e less
definitely associated with iheumatism and endo-
carditis than oidmaiy chorea is (vide infta,
"Chronic Piogressi\e Chorea")
Choi on de\ eloping after middle life is much
more likely to be a permanent disease than the
juvenile form
PATHOLOOA — Chorea Ims a clinical rathei
than a pathological existence, and the disease
is at piesent classed amongst "functional"
disorders Practically nothing is known of its
essential pathology It is only in severe and
complicated cases that the disease is fatal, and
at i>ost-moitem examination.*, veiy vaned and
inconstant appeal ances ha\e been found, amongst
which may be mentioned general hyperivmia of
the biam, embolism 01 throml>osis of cerebral
\ossels, and minute pen vascular hwmorrhagos
in the biam and spinal coid Sometimes hue
changes in the neive-cells of the eential ganglia
have also been described Hut an insurmount-
able objection to the acceptance of any one of
the above as the essential lesion of the disease
lies in the fact that any or all of these changes
may be absent and the results of examination
may be negative, the brain, spinal cord, and
penpheial nerves appearing absolutely normal
34
CHOREA
-so far, at least, as the present methods of
leuro-pathological research enable us to judge
iecent endocarditis, however, is found m a
peat majority of fatal cases of chorea.
Some time ago the disease was supposed by
tome to be due to extensive capillary embolism,
ind this view was thought to be strengthened
jy the fact that tho injection of btarch granules
nto tho carotid ar tones in dogs produces
jhorooid movements But most cases of fatal
shorea show no signs whatever of such embolism
Moreover, "canine chorea" is essentially a differ-
ent disease from chorea in the human subject
Tho nature of the choreic movements, together
with their cessation during sloop, points strongly
bo their origin from some irritable condition of
the motor colls of the cerebral cortex Such
% hypothesis is further strengthened by tho
Frequency with which the symptoms are con-
fined to one wde and by the frequent piescnce
of mental disturbance
Foi want of a better explanation, chorea is at
present classified as A " functional " dibordoi of
the nerve-cells But there can be little doubt
that some molecular or chemical change in the
neuron underlies all so-called "functional"
disorders, though as yet we are ignorant of
the preuso nature of such changes
It is not at all improbable that chorea in
many cases may be due to a toiin, probably
closely associated with the iheumatic poibou,
if not identical with it
That emotion frequently plays a pait as an
exciting cause is not antagonistic to such a
theory, for tho mental shock m such cases often
merely precipitates an attack in an unstable or
imperfectly developed nervous system already
partially poisoned by a toxin in the blood
Endocarditis is as frequent m cases which
have followed upon mental emotion as m those
which have arisen spontaneously, and yet no
one doubts that uudocaiditis IH duo to the
existence of a poison in tho blood Endo-
carditis is so common m choiea that we
conclude theio must be some close connection
between tho t\vo, and the fact that chorea so
often precedes the endocarditis shows that the
latter cannot be tho cause of tho chorea We
are thoiefore again driven to tho conclusion
that some common cause must bung about
both the chorea and tho ondoeaiditis
DIAGNOSIS — Ordinal ily chorea can bo dia-
gnosed at a glance The peculiar movements
are quite characteristic, and the history of a
recent onset distinguishes thorn at once from
athetosis following cerobial palsy in early life,
which is the commonest condition m which
similar moxoments occui. The movements of
athetosis have unfortunately been termed " post-
hemiplogic chorea," but tho diagnosis between
the two conditions is usually easily made, not
only from the "athetoid" character of the
movements, but also fiom the presence of
muscular rigidity m the athetotic limbs, with
a history of some previous cerebral attack (vide
« Athetosis," vol i p 319).
Tho rare condition called General Convulsive
Tic ("Tic Generalo") simulates chorea even
more closely, but can bo differentiated by
observing the systematic nature of the move-
ments in Convulsive Tic, the relatively long
intervals of rest between the movements, the fact
that the patient can always intermit them in order
to execute voluntary actions, and the froquent
presence of echolaha, copiolaba, or other ex-
plosive utterances and of forced movements
Sometimes difficulty arises in the diagnosis
of cases of " paralytic " chorea, where the out-
standing symptom is loss of power in one arm
Whon a child between seven and twelve years
of age is said to luu e gradually lost tho use of
one arm, without paralysis of leg or face, the
disease, as a rule, is chorea Careful observation
m such cases never fails to reveal slight choreic
movements in tho aftected limb
Tho few cases of chorea whore tho legs arc
chiefly affected may simulate atnxia of gait, but
tho choieic movements of tho limbs in the
sitting and recumbent posture aro suihiient
to differentiate tho two conditions
TREATMENT — Tho mental and motor symp-
toms of choiea, togcthei with the marked
influence which emotion and e\eition, mental
or physical, have in exaggerating tho choreic
movements, make it obvious that a most im-
poitant clement in the treatment of chorea
consists in the removal of all causes of emotional
excitement and physical or mental fatigue
The patient must not go to school lessons
must be stopped at onto and rest m bed should
bo insisted on, for seveial weeks at least, even
in mild cases When the patient w afterwards
allowed up, this should only be toi a short time
each day, gradually lengthening the time spent
out of bed
All sources of mental nutation must bo
avoided, and only suth occupations should be
pel nutted which mteicst the patient without
fatigue or excitement The child must not be
f lightened or threatened. A large airy loom,
if available, should be chosen for a bedroom,
and chcoiful companionship should bo piovided,
such as that of the mother or of a judicious
nurse, since mental depression might undo the
good pioduced by rest If there are other
ihildien m tho house, they should not be
allowed to go into tho patient's room, lest they
increase his mental and physical unrest
In cases with violent movements, care must
Ira taken to prevent the patient from falling
out of bod or injuring himself This can be
accomplished by la) ing the patient's mattress
on the floor m a corner of the room, woll padded
with cushions or pillows, to prevent him from
knocking himself against tho wall. If bod-sores
threaten, a water-bed should at once be procured
CHOREA
135
Treatment in an asylum is seldom necessary,
except in cases \\ith severe mental symptoms
where isolation at home is unattainable But
if a case is doing badly at home, transference
to hospital is often advantageous and expedites
the cuie
The diet should bo nutntious and easily
absorbed The more food the patient can take
the better In severe cases uhero deglutition
is unpaired, or \\hero from mental dulness the
patient does not take enough nomiahment,
nasal feeding must be resorted to Hughlings
Jackson gives alcohol — a teaspoonful of brandy
eveiy four hours — in sevcie cases of chorea,
and with excellent results Tho bowels must
be kept open, but strong cathartics .'ire to be
a umlcd
It is important that the patient should sleep
\\ell, and hypnotics must be given if necessary
As to diugs, arsenic is the classical remedy
It is given by the mouth, and the dose should
commence \vith throe or foui minium of the
liquor arsenicalis thiee times a day, mci easing
giadually to ten or fifteen minims If symp-
toms ot arsenical poisoning appear, such as
conjunctivitis, nausea, and gastnc pain, the
drug must be stopped for a few days and then
resumed m a someuhat smaller dose The
aohmmstiation oi large doses of liquor a r sen i calls
(fifteen to twenty minium three tunes a day)
from the hist, tor a period not longei than a
\veek, has sometimes yielded good lesults, but
if this mode of admimt*tiation be persisted in
for a long penod, it is not de\oid of risk
Aibonu in laige doses admiuisteiecl for a
lengthened period not only induces a hioumsh
pigmentation of the skin, but has sometimes
piodmed very mti actable penpheial ncuntis
In scveie cases chlotal hydrate is of gieat
service UK a h \pnotic and geueial nervous
sedative Some physumns keep the patient
continuously asleep ioi weeks by means of this
drug, but caution is necessaiy in such cases,
since the chloral sleep is sometimes followed by
maniacal excitement
Bromides tuo ot singularly little value m
chorea In very violent cases moiphia may
bo administered hypodeimitally, or it may even
be necessaiy to give chlorofoim to control the
\iolence of the movements, but such tie.itment
can only be of temportiry SCTMCC, it being much
bettoi to keep the patient undei the influence
of chloral In some cases antipyim is useful,
but care must be taken not to pioduco caidiac
failure, theieforo duimg treatment by antipyrm
the patient must be kept absolutely at icst
Valenanate ot zinc, oxide of zinc, hyoscme,
cannabis mdica, and physostigmme have all
been employed, but are of little use Sahcyl
compounds occasionally give good results, especi-
ally balol, but in other cases, again, they fail
entirely
The application to the spine of electricity,
faradic or galvanic, and the freezing of the skin
over the spine by means of other spray, \\ hich
have sometimes been employed, are of doubtful
value , and when we remember that the disease
is of cerebral and not of spinal origin, this can
readily be understood
During convalescence mild gymnastics are
often of service, and a change />f air often serves
to confirm £ho cure.
Finally, it must be lemembered that chorea
is a disease \vhich is prone to recur Each
successive attack must be treated on the same
principles, rest and feeding being more important
than medicinal therapeutics
Ilis,iiEi>iT\m ADULT CHOREA (Huntingtou's
Chorea)
Tins is a some \vhat raie disease which must
be caiefully distinguished from the ordinary
choica m mm
The disease was described m 1872 by Hunt-
ington ot fse\\ York as a form of chronic pro-
giessive thorea occurring hereditarily in ceitam
families thiough many generations, the malady
commencing in middle life, being associated with
mental weakness, and continuing until death
bnue its original description the disease has also
been observed with considerable ficqucncy in
Britain and on the continent of Europe
Tho complaint is markedly hereditary in
ceitam families and has been traced through
many successive generations Sometimes, how-
cvei, one genciation escapes and the disease does
not aitcnsaids icappoar in the family
Males and females aie equally affected, and
both sexes may transmit the disease, \\hich
begins, as a rule, in middle life, commonly
between the ages of Unity and fifty years.
It may arise without any cause whatever, but
sometimes it first becomes evident after emo-
tional excitement Thus in one woman, whose
niothei and maternal grandmother had been
similarly affected, the earliest symptoms came
on after the physical and mental shock of being
forcibly discharged by her employer, who thiew
hei down a thght of stairs
tiymptom** — The patient exhibits movements
of a choreic typo, usually first noticed in the face
01 upper limbs, giadually increasing m seventy,
and ultimately, in the course of years, affecting
all the voluntary muscles of the bodj The
motor symptoms are similar to those of chorea
minor, with giimacing, gesticulation, affection
of articulation, and almost constant play of m-
volimtaiy irregular movements of the eyes, face,
limbs, and tiunk The oculai muscles do not
necessarily escape, as sonic authors state Some-
times one side of the body is uftoctod for years
before the other Hide is attacked
The movements, as in chorea minor, cease
during sleep and are increased by emotional
excitement, but, unlike ordinary chorea, they
can be ancstcd when the patient desires to
136
CHOREA
execute any voluntary movement, thus the
patient can still write or thread a needle, even
when the disease is far advanced
Even up to a late stage the patient is able to
walk, but the gait is often cmiously irregular
The trunk and limbs undergo irregular spon-
taneous movements, the patient often suddenly
standing still after walking a few steps
Sensation is normal The deep icflexcs are
generally somewhat increased The heart is
unaffected
Mental weakness is usually piesent, com-
mencing .ts mere "facility" and gradually
advancing towards a degree of dementia. The
patient is often depressed, and suicidal tendencies
have sometimes been observed The patient
may at first be irritable or excitable, but, as the
disease pi ogi esses, the mental state usually be-
comes one of apathy The mental affection is
an insidious one and generally develops some
years later than the muscular restlessness, but
this is not invaiiably the case Mental weak-
ness may precede the motor phenomena
The disease is an incurable one and its symp-
toms persist throughout life, but life is not
necessarily shortened thereby The complaint
may last fiom ten to thirty yeais, and the
patient ultimately dies eithei fiom exhaustion
or from some mterturrent atiuction
Diagnosis — This disease is distinguished fiom
common choica chiefly by the histoiy of hcicdity,
which in ordinary chorea is vciy r.iro , also by
the ago of onset, the tendency to dementia, the
prolonged duration, and the progicssive nature
of the malady Chorea senilis, which may either
be chorea ininoi occurring at an advanced age,
or may be a variety of chiomc piogiessive
choica, is free from any hereditary tendency
and unassociated with piogiessive dementia
Pathology — As in chorea minor, the essential
pathology of this disease is quite obscuic It
is probably a degenerative process affecting the
cortical motor neurons Very various morbid
appearances have been found at autopsies, in-
cluding slight diffuse clnonic meningitis, changes
similar to those of general paralysis of the
insane, pachymenmgitis hcumoirhagica, dissemi-
nated mihary nodules of chronic inflammation
scattered in the \\hite and grey matter, etc,
but these are all probably accidental, and not
essential to the disease
Treatment can only be symptomatic Aisemc
is of little or no use Tomes and various
sedatives may be tned, but therapeutic results
have, so tai, boon entnely negative
CHRONIC PROGRESSIVE CHOREA
Apart from Huntmgton's chorea, other forms
of chronic progressive chorea occur unassociated
with any hereditary tendency Isolated cases
may begin in old age, in adult life, and recently
have also been obseivcd in adolescence (develop-
mental cJioiea)
These cases are distinguished from ordinary
chorea by their duration and by the absence of
rheumatic affections or of cardiac complications.
The motor symptoms are exactly those of chorea
mi noi, but they become progressively worse and
last throughout the patient's life
Such varieties of chorea aie obviously different
from oidmaiy chorea minor, which, though it
tends to relapse, ultimately in most cases be-
comes cured They are probably dependent on
a chrome degenerative process in the. cells of
the motor cortex, rather than upon any toxin,
as in the case of choica mmoi
KLRTIRICAL CHOREA (Dublin's disease)
This is a very rare endemic disease, \vhich
occurs chiefly in NOT them Italy and Lonibardy
It has been observed in both sexes and at all
ages The disease is a progiessivc one It com-
mences with a short stage of pains in the head,
neck, or Hpiue, soon followed by involuntary
spasmodic movements which diffei horn those
of ordinary thoica in being shoit, sudden, and
shock-like, sunilai to those elicited by electiical
stimulation
These conti actions usually commence locally
in one arm 01 one sido of the face, latoi they
attack the leg on the same side, and at last they
cioss over and invade the muscles of the opposite
side In addition, theie aie sometimes cpilepti-
form convulsions, which may be unilateral
As the disease progi esses, paralytic pheno-
mena are supei added, commencing in those
limbs in which the conti actions were eaihest
and most marked The palsy, which is accom-
panied by nmsculai atrophy and diminution of
faradic excitability, spreads all ovei the body
and becomes general Theie may be coiihidei-
able elevation of temperature Throughout the
disease the mind is unaffected
The complaint may last foi days, weeks, 01
months, and is usually fatal Death icsults from
cardiac failure 01 from coma Only in a few
cases does iccovery take place
The natuio of the. disease is undetei mined
No constant morbid changes have been found
On the whole, it seems probable that the disease
is due to some toxin of endemic origin which
attacks hist the eeiebial cortex and secondarily
the spinal coid
JDtaynati * — This disease has not been observed
except in Italy Else \\heie the only complaints
which may simulate elcctncal chorea are myo-
clonus multiplex (qv "Muscles, Diseases of
the ") and c crtam varieties of hysterical spasm,
both of which conditions have only to bo known
in order to be icadily distinguished from Dublin's
disease
The so-called Choiea ma)ot (Chorea magna)
must bo carefully differentiated from all the
truly "choreic" disorders It is not a chorea
at all, but merely a vanety of hysteria easily
distinguished fiom true chorea
CHOREA
137
CHOREA GBAVIDARUM
Chorea, rare in the adult, is perhaps a little
less rare in the pregnant This is, however, by
no means certain Of 439 cases in the British
Medical Association's collet live leport, 68 were
females between 16 and 40, and of these 7 only
were pregnant , of 28 delirious female cases, ovei
15 in the Kommune-hospitalet <it Copenhagen,
7 were pregnant and 1 iccently dehvcied The
pioportions in these ins Uncos are 1 m 9 and 1
in 3, while the propoition of pregnant \\omen to
adult women in general is between these ratios
find ncarei the highfi Nevertheless, the asso-
ciation of chorea and piegnauey is important
both for piognosis and tieatmont
Cases of chorea in pregnancy exhibit the same
lelatioiib to fright, iheiimatisiu, and cndocaiditis,
hysteria, family tendencies, and pievious choiea,
as cases of chorea in general Fifty-nine per
cent of fiist attacks occui in the hist pregnancy,
but the latio ot illegitimacy is little if at all in
excess of that of \\omcn in general Conespond-
ing to this, the ago at the1 hist choieic picgnamy
is usually undoi 25, but cases aie on tocord at
all ages up to 40 Choiea may umu in several
picgnancies, the laigost number of iccoided
attacks being •">, but choierc piegnaney may be
preceded 01 succeeded by piegnancy free from
choiea Full) half of the attacks began in the
fust three months, and a thud in the middle
three months A iew cases me on lecord where
(hoica began during the pueipeiium, and two
01 three somew hat latei
()i cases whcio the piegnaney ends spon-
taneously t\vo-thiids .110 delmrrd at term, the
piopoition of aboition being thus higher than in
geneial In about 40 pei cent of the cases that
ieco\ei the choiea toi inmates betore the end of
the pregnancy Theic is no oMdoiuo to show
what influence the death of the ia'tus, bcfoio
deli\ery, has on the chorea, m a few cases the
poiception of the ia-t.il movements has exagger-
ated the chorea Kecovery after delivery is, as
a rule, gradual, as it is in choiea apait iroiu
piegnancy, but m a few recovery is sudden , in
one case the choiea became chionic The mor-
tality cannot be exactly determined, but is
certainly less than 1 in 5, and a consideiahlc
number of the fatal cases die from causes other
than the chorea In less than 3 per cent of the
cases insanity followed the chorea, recovery
taking place in a few weeks or months In a
numbei of cases infective piocesscs have com-
plicated or followed the choiea
The treatment of chorea in pregnancy is
prnnaiily the same as the treatment of chorea
generally Aisemc and salol, and the sedatives
and narcotics, including general anaesthesia,
must be employed according to the indications
of the individual case Whore the case is severe
or becomes worse m spite of such treatment, the
induction of abortion or of premature labour is
justified In practice this has not always given
satisfactory results, but the cases were of great
severity, and sometimes the delay had been too
gieat The induction should lt>e made under
anaesthesia, which may reasonably be prolonged
till the completion of the delivery In some
cases digital dilatation of the cervix has stopped
the chorea In less seveie, cases and those
which improve undei general treatment, it is
best to wait spontaneous labour and to watch
that, interfering only if this seem specially
icquired
CuoHErc
Theie is probably no special form of insanity
that can pioperly be called Choreic Insanity.
In c^ciy patient sufftnng from choiea there is
UHU illy some mental disturbance The patient
may be dull and listless with apathy and loss of
memory , but these mental symptoms being so
slight they aie overlooked , on the other hand,
howe\ei, they may become so se\ero as to call
for immediate treatment
JOttioloyy — Mental complications with chorea
are nioie common with pregnant women, girls,
and young men than with childien Usually
there is an unstable inheritance
S'v MrroMS — 1 Choren Muma — The excite-
ment larcly begins bcioie the end of the first
and after the foiu th week ot the outbreak of the
choiea Often it is most dimcult to say when
the bounds of sanity have been passed, as the
impulsi \eness, agitation, or loss of control grow
giadually Sleep becomes more and more inter-
rupted until it is finally lost altogether The
patient becomes destiuctive and dirty in his
habits Hallucinations of sight and heaimg
may be piesent He is incoherent, is ted mith
dithculty, and there is steady failure of physical
c ondition
2 A ifi tri it <l Mela nt holm - Patient is depressed
with self-accusations, restless, despondent, and
belie\es that ho will never recoxer There is
oiten persistent lofusal of food This type is
more common 111 joung pregnant women.
3 At tiff Dclntam —These cases differ from
those of acute mama by the seventy of both the
mental and somatic symptoms The mental
condition resembles that of acute delirious
mania There uie marked fever, hallucinations
of sight, refusal of food, constant excitement,
insomnia, gieat piostration and exhaustion, and
the termination is often fatal
4 Delnwontil Insanity — Delusions of perse-
cution with the belief that they are being
annoycxl may develop in cases ot chronic chorea.
5 »SYi/^wr — The mental hebetude and inatten-
tion that is so common in choreic patients may
become more profound, and they pass into a
stuporoso state The memory is commonly very
defective in these cases
Motbnl Attatoniy — There are at present no
definite macroscopical 01 microscopical changes
138
CHOREA
known that can be said to be the actual cause
of choreic insanity,
Prognosis — The prognosis is usually good in
the mania and agitated melancholia of chorea
With acute delnium the condition is much moio
serious and the prognosis must be always
guarded, but when the patient once begins to
improve there is seldom a relapse.
Delusional insanity or stuporose cases RIO
commonly chronic
Tieatment — This is largely upon general lines
Good feeding with Urge quantities of milk and
eggs, custards, and solid food, if possible The
more acute the attack the greater must be the
amount of food given 1 f nourishment is refused,
artificial feeding must be icsorted to Stimu-
lants aic usually requited in severe cases. The
bowels must be kept open, and salines are re-
commended for this puipose For violence the
patient must be placed upon a mattress on the
floor and surrounded by other mattresses For
persistent insomnia hypnotics must be used
Sulphonal, 30 giams foi a child over 13 yeais,
for adults this can be repeated morning and
evening if necessary In agitated case s morphia
bimeconatc is often useful Chloial is also
recommended
. — The dancing mama,
epidemic in charactci , chorea Germunoium
ChoHorna. — Ohonon-epithehoma or syn-
cytioma mahgnum See PRKI,NA\CY, OVUM AND
DECIDUA (EpitJiehonm of the CJwnori) , PUKR-
PBRIUM, PATHOLOGY (Saicoma-Deciduo-Cdlulare
or Deciduoma Maliynum)
ChOriOn. — The outer fcotal membrane
See FCEPUH AND O\UM, DEVELOPMENT (Foetal
Membranes, Placenta) , LABOUR, RETENTION OF
PLACKNTA (Fiaqments of Memlnane) , PHYSIO-
LOGY, REPRODUCTION (Development) , PREG-
NANCY, DIU.VOSIH (Jfydatid Deyenei ation of the
Chouon), PREGNAVCY, AFFECTIONS OF THE
OVUM AM) DECIDUA ( Veiicuftu ot HyJatul Mole),
PREOVAVCY, AFFECTIONS AND COMPLICATIONS
(Causes of Death, dining Pieqnanty) , PREG-
NANCY, HEMORRHAGE (Antejxtifum, Afyjoma
Chont)
Chorlon-Epithelloma. See PREG-
NANCY, OVUM AND DECIDUA (fijutftehotna of the
Chorwri) , PUBRPERIUM, PATHOLOGY (Narcoma-
Dedduo-Cellulate ot Denduoma Maliynum)
Chorold, Diseases of.
STRUCTURE 138
NORMAL APPEARANCE 131)
CONGENITAL AFFECTIONS 139
CHOROIDITIS 140
Exudative 140
Vaneties 141
Ruppuratwe 142
I RiDO-CncmoiDiTis 143
TUBERCULOUS AFFECTIONS
GUMMA
SARCOMA, ETC.
CIIOROIDAL DEGENERATION
INJURIES OF
144
144
144
145
145
See also ACCOMMODAI ION (Chanyes in t/te Cftor-
Old) , CHEKK, FISSURE OK , EYEIJALI^ INJURIES OF
(Ruptute of the C/totoid)t AlKNiNoins, TUBER-
CULOUS AND J INTERIOR BASIC (Ojththatmoscopic
Examination), OCULAR MUSCLES, AFBECTIONS
OF (Nysfaqmus, Causes) , PALATE (Facial Cleft,
Cololomi of Choroid), PII\HIOLOG,Y, THE SENSES
( VlSlOtl) , PiGMENIS OF THE BODY (CJlOTOld)
THE ehoroid is the pobtcnor pait of the tunica
vairulosa, the antenoi part being formed by the
ins and ciliary body In its extent it reaches
from the ciliary body to the optic disc, and lies
between the scleiotic externally and the retina
internally On miuostopic section it presents,
trom without mwaids, the following layeis —
1 The lami uajii sm — Tins consmts of lamclltc
of loose connective tissue, containing blanching
pigment cells , it adheres to the sclerotic when
that is separated from the choioid, and therefore
it is sometimes descubed as belonging to that
tissue
2 The lamina *u)na(hoioule<i is sinulai in
stitiftme to the lamina fusca, being composed
of lamella) of blanched pigmented connettive-
tissue ( orpusclcs and a nct\\oik of elastic tissue
The spate between this l»uer and the List is
lined by endot helium, and is considered to be a
lymph space
3 The lamina vasculota consists of a dense
network of large mtei communicating veins so
closely connected th.it in Homo parts the
mtervascular spaces are less in diamctei than
the veins themselves This venous plexus ends
abruptly at the oia serrata These \eins are
the tnbutarieH of the veme vorticosjo Within
the f ones ti at ions, \\hirh are chiefly fusioirm in
shape, are pigmented connective - tissue cor-
puscles, the presence of which renders this
membrane uniformly dense and reflective in
most eyes , a deficiency or excess of these pig-
ment-cells will cause the outline of the choroidal
vessels to be seen
4 The chorio-capillan*) or memt/rane ofRuyvchj
is a reticulated vascular membrane of closely
intercommunicating capillaries oi large diameter,
the meshes of this network are small Here the
venue vorticosro begin in capillary whorls, the stars
of Winslow There are no pigment-cells in this
layer, and few, if any, round cells A delicate
structureless mcmbiane, the elastic layer of
Mattler, is supposed to exist between this and
the former layer This Sattler believes to be
the remains of the tapetum, a definite layci
found in the ehoroid of certain animals In
carmvora the tapetum is composed of endothehal
cells containing minute crystals, producing a
shining appearance in the dark In other am-
CHOROID, DISEASES OF
139
mala it is fibrous in nature, and, since the retinal
pigment is absent from certain spots, interfer-
ence of light is produced, causing a similar
appearance
6. The lamina vitrea, or membrane of Uruch,
is an hyaline membrane It is continued foi-
wards into the ciliary body and ins It supports
the pigmentary epithelium oi the retina, and
just as this layer, foimcrly thought to belong to
the choroid, has been shown to be epihlastic in
origin, so the lamina vitica w in all probability
a layer of the retina, and not of the choroid,
being produced oiigmally from the culls of the
pigment layer of the letina
The choroid is almost completely supplied bj
the *km t posterior cihniy ai tei te* They are ten
or twelve in nurnboi, and picne the sclerotic
close to the optic neive, pausing tlnough the
lamina fusca into the deepei part of the lamina
buprachoroidea , they divide dichotomounly, and
pass into the capilUues of the chono-capillaiis
Except in the region of the optic nerve, whoie a
cucular ai tonal anastomosis exists aiound the
disc with small branches of the aitena centrahs
ictinie, the anastomosing branches being called
the cilio-i etuuil ai tei ten, the branches anastomose
little w ith each othci Antenoily tluy receive
a few communications fiom the artenes of the
ciliary legion
The vein* of the choroid anastomose \eiy
freely together , they do not <u company the
shoit postonoi ciliaiy aitenes, but ate aiianged
in cm ves, venae vat t iroscp, as they comerge to foui
or five pimcipal ti links , these pieice the sclciotic
veiy obliquely about half-way between the optic
nerve and cornea to join the ophthalmic -vein
The lymphatu «t oi the choioid help to regulate
the mtia-ocular picssuie I Jet ween the lamina
fusca and the lamina suprachoioidea is a lymph
space, which communicates by means of pcn-
^ oscular sheaths Himoundiiig the vcnrc vorticosrc
with the lymph space \\ithm the c.ipsulc of
Tenon
The neive* of the i hoi old aic domed fiom
tho long ciliaiy blanches of the nas.il blanch of
the first division of the fifth neive, and fiom the
shoit ciliary branches of the lenticular ganglion
They are chiefly ^aso-motoiial in action, and
form in tho lamina supr«iehoroidea a plexus, in
tho meshes of which ganglion cells aie found
THh Arrt ARA^LL n* iur J/FALUIY CUOKOID
must be carefully studied befoio \\e can diagnose
pathological conditions
The colour of the/Nnc/iM orult seen by icflect-
mg light from the ophthalmoscope is due to the
following causes — (1) The blood contained in
the chorio-capillans and lamina -\asculosa, (2)
the pigment-granules contained in the pigmonted
layer of the retina, tho interstices of the vascular
layer of the choroid, and the lamina fusca and
lamina miprachoroidea , and (3) the sclerotic,
which reflects a certain amount of light through
the retina and choroid
When pigment is altogether absent from both
retina and choioid, as in albino^ we get a light
yellowish icd colour reflected from tho blood
within the capillaries, whilst the interstices
between tho latter are seen to be of a lighter,
almost white appeal ance, owing to the reflection
from the sclerotic beyond the lamina fusca, and
thus a fairly well-defined outliDe of tho choroidal
vessels is obtained
In /<w penon*, where the pigment-gianules
contained within the cells are of a faintly blown
colour, the fundus is yellowish red, and the
vessels of the choroid can often bo seen, although
less distinctly than in albinos
In motlerately daik pet was this pigment
becomes of a deeper brown, and all details of
tho r ho? oid are hidden, the fundus presenting
a light brownish red coloui, with no visible
choiuidal vessels If, however, as is occasionally
the P.ISC, pigment is scarce in the pigmentcd
layer of tho letina, while abundant in tho
choioid, a netwoik of led ^esselH is seen upon a
dark backgiound, the so-called rhoioide toytde
In newoe*, and all ilatk inte*, tho pigment is
so abundant as to pi event almost all red
choioidal ic flex, the fundus assuming a biownish
giey, or e\en a slate colour
The colour of the fundus vanes \eiy much
with the intensity and colour of tho light used,
with the state ot dilatation of the pupil, and
with the refiactne condition of the eje It is
bnghtei, ctrtetts jMiiil/H«, in proportion to tho
numbei of rays of light that can be thiown into
the eye
CoM,rMJAL AtUtlW\b OF 1HE ClUUlvW —
Coloboma of the cfioioid is a congenital deformity,
consisting in the absence of a more or less con-
siderable poition of this pait of the tunica
vosculosa, and is usually found in the lower and
mteinal part of the globe When examined by
the ophthalmoscope it appears of a bnght bluish
white colour, with clear cut pigniented edges.
The sin face of the scleiotic often appears very
niegulai, is ciossed by retinal vessels, and
frequently has upon it small aggregations of
pigment The extent of tho coloboma is Aeiy
\anable, it usually leaches fiom the edge of
the optic disc ueaily as fai as the ciliary Ixxly
It may cmb'ace the optic disc, in which case
the lattei is changed in appeal ancc, and looks
as if it weie hypenvmic by contiast with tho
white area round it It may occui m the
yellow sj)ot legion, maeulm coloboma , it may be
\eiy localised, noimal choioid being seen all
round it , it is often accompanied by eolol>oma
indw The retina is often involved in the
coloboma, though it may be present over the
whole site Occasionally coloboma of the
choioid occurs in both ejes, but when unilateral
tho left cje is most commonly affected There
is a large scotoma in the -visual held corre-
sponding to the coloboma, but otherwise the
sight in most cases is fairly good The scotoma
no
CHOROID, DISEASES OF
is not necessarily absolute, as the letma may be
present.
The cause of the defect is piobably due to the
formation of adhesions beta ecu the developing
retina and tho mesoblast, the Utter of which is
not differentiated into choroid and sclciotic
Tins usually takes place m the position of the
retinal fissure, and thus accounts for the usual
position of tho colobonid It may, howevei,
take place in any pait of the ictina , hence the
occasional occurrence of the coloboma elsewhere
Albinism, or congenital absence of pigment
throughout the body, may be lelative or
absolute In abvnlute albinism the pupils and
irides appeal pink ftom the reflected light from
the choroid, the mdes also on account of the
blood contained in then vessels This con-
dition is usually attended with detcctno visual
acuity, photophobia, and nystagmus Upon
ophthalmoscope examination, the choroidal
vessels aie seen most distinctly as a pink
fenestrated membrane upon a pale, almost
white, backgiound The hair is usually white
throughout the body In telnttve albinism, the
hair is a pale stia\v coloui , the mdes piesent
a pale purplish coloui, and do not completely
shut oft tho choioidal leflex, the symptoms also
are less maikcd Theio is a tendency to acqunc
pigment as the child gio\\s , the improvement,
howevei, is laiely moio than a change fiom the
absolute to the lelative condition By way of
treatment, any existing enoi ot leii.iction must
be cnnected , daik glasses should be \\oin, with
or without a diaplnagm, to cut off some of the
light. Pcupheral tattooing of tho coinea has
been pcrfoimed for the same object
Comjftutnl uesmnt is a peculiai greyish white
ciescentic patch immediately below or, in laiei
instances, to the oiitoi side of the optic disc
The disc, excluding tho crescent, is usually oval,
but with it appears circular or slightly oval in
the opposite direction These crescents present
no marginal pigment, w Inch is so often seen in
myopic descents , besides, the latter are untidily to
the outer side ot the disc It is vei y pi obablo that
this c roscent is a pai tial coloboma of the chot oul
CHOROIDIII* — Inflammation ot the choioid
is accompanied by infiltration and exudation,
which may be reabsorbed with 01 without
atrophic changes, 01 may piiss into the stage of
suppuiation If the morbid process be limited
to the choroid propei, it infrequently unattended
by external signs ot inflammation, being leeog-
nised chiefly by visual troubles and ophthalmo-
scopic appeal antes When the other poitions
of tho meal tract —the ciliaiy body and inn —
aie invohed in the process, as is usually tho
case in acute and suppmatixe forms, the ex-
ternal signs of these inflammations are always
piesent Tho two chief varieties of choroiditis
arc plastic 01 exudative choroiditis and suppura-
tive choroiditis Besides these, we have forms
of choroiditis accompanied by inflammation of
neighbouring parts , these are — mdo-choroiditis,
retino-choroiditis, and sclerotico-choroiditis.
PIAVTICOR ExvDAnvK CnoRoiDiiis — JEtioloffy
— The most common cause is syphilis, inherited
or acquired In the acquired foim it usually
occuis to wax ds the end of tho fust year after
the prmiaiy infection, 01 during the begin-
ning of the second yeai Inherited syphilitic
choioiditis is commonest between the ages of
six months and thieo years , it may occur, how-
ever, much latei together with inteistitial
kciatitis Other causes of plastic choroiditis
aie tuberculosis, gononhou, the simple and
ptofound antennas, and menstiual disoideis
Many chronic cases occur to which no definite
cause can be assigned
Nym}>tf>ni* — I'lastic choioiditis is the most
common form, and presents itself under soveial
forms, the symptoms varying with the extent of
the aiea affected, and with its position with
regaid to the maculai legion When unattended
with cyclitis or iritis theie aie no external signs
ot the disease Subjective <<ymjttoni* are usually
the earhei and moic impoitant indications of
the disease, but they may be completely absent
although the ophthalmoscope shows gioss
changes The patient (om plains ol seeing
lights of a pale blue 01 led coloui — -pkoiphenes
— at night, when the eyes aie dosed and the
loom is daik In tho daylight he sees largo
floating specks, especially when looking at a
white object, these aie largei than tho oidnury
musue vohtantes, and tend to obscme the vision
by settling upon one poition of the object looked
at Distortion of the outline of objects —niftn-
HUH jithnva — is also .1 eharactenstic featuie,
especially when the exudative change is situated
in the maculai region , it parallel stiaight hues
are held befoio the eve they will appear curved
in vaiioiiH ways Miciojtsm— objects appearing
smallei than normal — and nuicto^in — objects
appealing too laige — aio symptoms sometimes
piesent The patient may complain of daik
spots in the visual field — jmsitive wotomatu, — or
these may only be found by carefully testing
the field with thepeiunoter — net/atnv *t.otomat<i
It will then be found that its whole area is not
intact, but that, according to the position and
extent of the disease, theio will be small and
laige areas in which vision is either defective 01
altogether absent — telative or absolute *cotomat<i
The light sense is also appreciably diminished,
especially when there is cloudiness of the
vitreous In some cases the patient will com-
plain ol .1 dull aching pain at the back of tho eyes
Ojththatmwropic A?ir/jt« — Recent patches of
choroiditis appear as yellowish, ill-defined areas,
lying beneath the retinal vessels upon and in
the red background of the choroid. These
patches may bo more or less obscured by a
necmorrhapo from a choroidal vessel, this being
sometimes the earliest sign of the disease Tho
yellow exudation may entirely disappear after
CHOROID, DISEASES OF
141
sonio weeks, leaving, m rate cases and under
proper treatment, the choroid intact , but mon»
commonly, as it disappear, the affected area is
found to be moro 01 less atrophic, gradually
becoming whiter, with the choroidal vessels
showing up, pigment at the same time appear-
ing round each patch and within some of them ,
crystals of cholcsterin may be seen with some
of the patches Still latei the choioidal atrophy
presents the appearance of \\ hi to patches, ringed
by pigment, with no traces of choroidal vessels,
but crossed unmteiiuptcdly by the letmal
vessels It is not uncommon to find both old
and recent patches in the same e_ye The in-
flammation usually attacks the adjacent retina ,
indeed, the exudation often extends through the
retina into the vitreous The vitreous is, there-
fore, often cloudy owing to the pieseuce of fine
opacities This is moie paiticularly the e.ise in
syphilitic choioido-rctimtis The nebulous con-
dition of the vitreous not only interferes with
the patient's vision, but pi events the details of
the fundus from being clearly seen , the oxist-
emeof cloudiness of the vitieous is, therefore,
always suggestive of choroid itis, although hyalitis
without choroiditis is sometimes found Caie
must be taken to exclude a nebulous cornea, as
this will cause a haxmess of the fundus veiy
sinnlai to that produced by fine \itreous opaci-
ties On the other hand, a hazy vitieous will
make the outline of the optic disc appeal
him red, and thus simulate papilhtis
Patholnf/y - When a rec ent patch is examined
microscopically, we find a clustei of lound and
fusifoim colls in the lannn.i Mtiea and the
choiio-capillans, \\ith gie.it engoigement of the
vessels, and peihaps one or two h.jumorihages
The pigmeiit-layei of the letina is then un-
affected As the disease pi ogresses the cells ot
the pigment -layer prohfeiate, and the part
which is immediately opposite to the patch
becomes absorbed, giving it a white appeal ance,
the pigment becomes accumulated at the edges
of the patch, and the inflammation extends to
the layct of lods and cones, find the outei granulai
layer of the retina, with small-celled mhltiation
Later, this inflammatory exudation becomes
absorbed, and gi\es place to cicatricial tissue,
but the stiuctuies involved — viz the outei
granular layer, the rods and cones, the uveal
tract, and the vessels of the choioid — are
destroyed, and their place occupied by this new
connective tissue
Vanettek — Many different kinds of plastic
choroiditis are found The following may be
mentioned as those more frequently met with
(1) Disseminated, (2) Central, (3) Peripheral ,
(4) Diffuse exudative , (5) Myopic
(1) Disseminated chmoulitts consists of numer-
ous lound or 11 regular spots scattered over the
fundus Those pass through the changes
mentioned above, and mostly end m patches of
complete atrophy. They may become confluent,
involving the whole 01 the greater part of the
fundus The optic nerve may become involved
in the process, in which case it becomes first
hyper&ennc and finally atrophic This form of
choroiditis may easily be mistaken for guttate
(hotoidifis of Tail (pt 145)
(2) CentitU ffioioidttm consists of exudation
in the macular region, foimang an iriegular,
moro or less circular patch, with considerable
pigmentation Vision is impaired, and a large
central scotoma is present This is especially
frequent in old people, where a very chronic
inflammation, without much pigmentation or
exudation, is followed by well-defined atrophic
changes In such cases the fenestrated arrange-
ment of the choroidal vessels is clearly seen
This wnile form is usually bilateral, and must
>>e carefully sought for before the extraction of
all senile cataiacts, as its presence will greatly
modify the prognosis Before a diagnosis of
amblyopia is mode, either congenital or toxic,
the macular region should be carefully examined
for central chorouhtis
(3) PenpJietal 01 ante-not chmoiditit is that
form in which only the peripheial parts of the
(hoi oid are affected Owing to the outlying
position of the lesion, direct vision is but little
disturbed, and the disease may bo easily over-
looked unless the peripheral portions of the
fundus «iie caiefully examined
(4) Dijfuie exudative (.hoi ouliti*, extending
over the whole fundus, is sometimes associated
with syphilis Although the whole choroid is
affected, yet the deposit of lymph appeals to
assume the foini of cncumscribed patches, vary-
ing somewhat in tint horn a yellowish red to
white, with pigmentation according to the stage
of the affect ion It is always moie 01 less
obscuied tiom view by hue dust-like opacity of
the vitreous, and not miiequently laige mem-
branous floating opacities ot the vitreous are
picsent The vitieous tind the letina may ulti-
mately become cle.ir, and then the ophthalmo-
scope icvcals moie definitely the laige atiophic
patches in which masses of pigment aie heie and
tkoio distiibuted Such eases, when they have
arrived at an advanced stage, aie often difficult
to distinguish from retmittt jiujmentow, (see
" Ketimtis ' ), for the letmitis secondary to syphi-
litic choroiditis tends to simulate that discvise
Pciipheiul retinal pigmentation, night-blindness,
and contiaction of the visual field occui , and it
is only by the piesence of vitieous opacities,
patches of choioidal atiophy, relative* distension
of the veins, together with perhaps concurrent
nitis or cychtis, and a definite history of syphilis,
that the right diagnosis can bo ai lived at The
visual held, too, may help, f 01 in many instances
there is no peiipheial contraction, but a ring
scotoma, which is almost pathognomonic of
syphilitic choroido-retimtis
This kind of choioiditis almost invariably
affects the retina to a considerable extent
142
CHOROID, DISEASES OF
(0) Myopic choroiditis, see Sckrotico-choi-
aiditu
Prognosis of Ffavtic Chmoiditis — Plastic
choroiditw runs a chronic course, its worst
feature is a tendency to recurrence Many
oases are so chronic that they extend over years
without perceptible change , while others present
new spots of exudation from time to time, until
the choroid is ultimately covered with atiophic
patches Tn bad cases the optic nerve and retina
are involved, and partial or total blindness
results Vision, however, may be almost com-
pletely restored so long as the macular region
is free Central changes, like peripheral, aie
attended with subsequent atrophy, which gives
rise to permanent and absolute scotomata;
consequently, direct vision becomes completely
lost Diffuse exudative choroiditis is invaiiably
attended with giadual failure of bight until
complete blindness ensues
Treatment of Plastic Choronditi* — It is neces-
sary to find out, if possible, the cause of the
disease A history of syphilis can often bo
elicited, and should the disease be active, mer-
cury m some form must be administered, either
with or without iodide ot potassium , the sub-
conjunctival injection of mercury has been
warmly arhouatcd by vaiious Continental sin
geons, and the discussion of this and othci
methods of tieatment will be found under the
head of " Iritis " Other constitutional causes
require general treatment Locally, if there is
active inflammation, as shown by dull pain,
diffuse vitieous ha/e, and fiesh exudations,
leeches applied to the temple, diaphoiosis by
hot-air baths or pilouirpme hypodermically in-
jected, and profuse purges, aio necessaiy
Counter- n ritation by means of the Argyll-
Robertson method frequently helps to clear up
the condition This consists in rubbing into
the skm of both eyelids puio silvei nitrate until
vesication is pioduced The eyes should be
piotected fiom the light by tinted glasses ,
they should be rested as much as possible, and
no near \voik attempted It may be necessary
to atropiniso the eyes to prevent accommoda-
tion.
Should there be no history of syphilis, it is in
many cases still advisable to try the mercurials
and iodides, as great improvement is often
obtained by their use independent of any syphi-
litic history If the geneial health is run down
it must be supported by a nutritious diet,
regular outdoor exercise, and by the exhibition
of tonics, such as iron, strychnine, quinine, etc ,
local treatment must also bo adopted as indi-
cated above It is advisable in most cases of
choroiditis to avoid alcoholic stimulants
SvppVRAiivE CHORQWITIS is a diffuse suppura-
tive inflammation of the choroid, and is always
attended w ith suppurative indo-cychtis There
is, in fact, a general inflammation of the tunica
vasculosa, which usually spieads to the other
tunics of the globe, and gives rise to that condi-
tion known as panophthalmitts
Etudoqy — The causes of suppurative chor-
oiditis may bo divided into three groups —
(a) Injury, of a penetrating nature, if septic
infection by pyogemc matter is produced Opera-
tive measures on the eyeball, where due aseptic
precautions have not boon taken, may be placed
under this category
(b) There may be an extension of an inflam-
mation elsewhere, such as from a septic ulcer of
the coinea
(c) Inflammation of the choroid may be the
result of metastasis Of metostatic choroiditis
the most important is the puerperal foim,
occurimg as a symptom of pyuemia, usually in
the second week aftci delivery It is also occa-
sionally found m ulccratwe endocaiditis, cercbro-
spmal meningitis, and during the acute specific
fevers It is duo to septic embolism of the
retinal and choroidal vessels
The symptoms from the hist are those of
intense inflammation The eyelids are red,
swollen, and oodematous, so that it is with difh-
culty that the eye can be examined , wore it not
fot the absence ot discharge, the condition
might be mistaken fot puiulent conjunctivitis
There is threat chemosis and conjunctiva! injec-
tion The cornea, is ha/y and anesthetic , the
ins muddy and immovable, with a somewhat
dilated pupil The .interior chamber is shallow
<ind often contains pus (hypopyon) Theie is
slight proptosis, and the tension is somewhat
raised If the media me sufficiently cloai the
exudation into the vitreous can bo soon as n
yellowish leflux
As time goes on theie may be a gradual sub-
sidence of the symptoms, the proptosis diminishes,
the inflammation subsides, the tension falls, and
gradually a general shrinking of the whole globe
(jtfctkun Iwlbi) occuis In the acute torm, how-
ever, suppmation occurs, with maiked constitu-
tional symptoms High fevei, vomiting, and
violent pains ensue, the proptosis inci eases,
the lids become more swollen, until the eyeball
givos way aiitetioily, with escape of pus and
disappeaiance of the acute symptoms
Pathology — Suppurative irido - choroiditis is
attended w ith suppurativo rotimtis , the vitreous
also, participating m the progtessive and de-
structive inflammation (suppurative hyalitis),
becomes destroyed and leplaced by pus, and
the eyeball is converted into an abscess-cavity.
In such a state either the cornea will slough
and the pus be dischaiged, or the pus will be-
come inspissated by absorption of its liquor
puris , in either case the globe will shrink In
many cases the exudation in the vitreous is more
punform than purulent, and the yellowish white
reflex seen has a somewhat similar appearance
to gliorna retinae Hence it has been termed
pseudo-ghoma The punform exudation often
undergoes partial organisation, and so the
CHOROID, DISEASES OF
143
ophthalmoscopic condition may remain foi some
weeks after the subsidence of activo inflamma-
tory changes, eventually, however, the eyeball
is sure to shrink, become puckered and haidened,
and in some cases the choroid will undergo
ossification
Micioscopically the choroid will be found to
bo greatly thickened and exceedingly cellular,
the cells aggregating into clusters which form
small abscesses, these soon coalesce and con-
vert the choioid into a diffuse suppurative tract
The inflammatory changes in the iris, ciliary
body, letma, and Mtieous are similar to the
microscopical characters of inflammation found
in other parts of the body It is advisable to
mention, however, that the paitially oigamsed
exudation in the uliazy body looks imdei the
microscope not unhke a nielanotic sarcoma,
on account ot the complete derangement and
multiplication of the pigment-cells The clinical
history, together with the condition of the
vessel-walls, will explain, however, its natuie
In ruetastatic choioiditis it is often possible
to find the infecting emboh, which can bo shown
to contain pyogenic oigamsms, the streptococci
being the most common
Di<KjnoM\ — The main difficulty is to dis-
tinguish between a chronic and subacuto form
of suppuiative chounditis and ccitam intra-
ocular giowths, of which gliorna is much the
most common The diagnosis depends chiefly
on the histoiy, the piesewo 01 absence of
leceut inflammatory signs, and the tension of
the globe Suppmativo choroiditis is usually
piocuded by a perforating mjuiy, 01 by a se\eie
illness such as a specific fovci Again, signs of
recent iritis will be seen, and, lastly, intia-
ocular neoplasms, though at first they may be
piesent in a globe of noini.il tension, soon
pioduce a use of tension with all the signs of
secondaiy giant oma — suppmative choroiditis, on
the othci hand, causing a fall in the tension
Othei points to help will be the age of the
patient, glioma only occun ing in young children,
and the appeal an ce of the reflex, which is of a
mm h more glistening appearance in glioma than
in pseudo-ghoma
Pioynow —The diseased eye is sure to be
lost, so far as sight is concerned, and will in-
evitably pass into a state ot atiophy In all
cases the question of sympathetic inflammation
in the other eye has to be carefully considered
(see " Sympathetic Ophthalmitis ")
Treatment — Local leeching, hot fomentations,
combined with moiphia, either hypodormically
or by the mouth, are useful in allaying pain
As soon as pus is evidently accumulating in or
behind the aqueous chamber prompt surgical
interference is indicated If the eye be loft to
itself there is considerable nsk of the inflam-
mation extending along the optic nerve to the
brain and its membranes, and so causing a fatal
termination. Excision of the globe is, in my
opinion, the boat and safest way of ti eat mg this
severe condition, great pains being taken after
the enucleation to treat the socket autiscptically
Some suigeons, however, are doubtful as to the
propriety of removing an eye whilst in this in-
flamed and suppurating condition, and prefer
fust to make an incision through the anterior
part of the globe so as to relieve pun, tension,
etc , and to give a free outlet to the pus,
postponing the excision until the inflammatory
symptoms have subsided
IjiiDO-CiHUtviDiu* (uveitis) is an inflammatory
condition involving the whole uvoal tract It
may bo acute or cfaonu
Acute Indo-fttortMlitis is cither suppurative
(tee "Suppurative Choroiditis") or sere-plastic
(we "Sympathetic Opthalmitis")
(Jhtonu mdo-chorotditiv attacks each part of
the uveal tiact either simultaneously or suc-
cessively It is very often preceded by an
acute attack of ititis 01 choioiditis Subacuto
exacerbations occur from time to time Its
tendency to relapse is its piedonnnatmg feature ,
yeais may pass away before there is a per-
manent cessation of inflammatoiy symptoms
The prevailing clinical featuies .ire evidences of
iritis, ( yclitis, and choroiditis, such as posterior
syuechi.e 01 pigment on the lens capsule , thin-
ning of the in tic tissue, so that m some cases
the dull choroidal reflex may be seen through
the leticulum of the iris, as if through a curtain ,
thinning of the scleia over the cihaiy body,
irom chiomc cychtis, which allows the blue
ciliary body to bo seen through, eventually a
cihaiy staphyloma may appear Numeious
and large vitreous opacities are seen, and, if
the vitieous is not too cloudy, patches of
choioiditis and choioidal atrophy, with general
thinning of the choioid, may be made out
Posterior polai cataiact or iriegular opacities
in tho lens aie not uncommon, and at last the
whole lens may become cataractous Subjective
signs «ne present, namely, defective vision,
sometimes amounting to bare perception of
light, phosphcnes, dull aching pains in the eyes,
etc Tho tension is usually slightly laised at
fiist, but soon becomes subnoimal (T-l or T-2)
The prognosis is unfavourable The disease is
usually sjrimetiical, and complete blindness
will almost cuitamly ensue sooncx 01 latei
Tirntment — Little can be done beyond treat-
ing the symptoms and suppoitmg the general
health Iodide of potassium assists in some
cases, chiefly on account of its alterative action
and its poweis in aiding the absoiption of all
chronic inflammatory exudations Mercunal
inunctions are also useful for the same purpose
Iritis must be treated m the early stage by
instilling atropme Increase of tension is rarely
present, and certainly is never sufficiently pro-
nounced to necessitate operative interference.
RsriNO-CuviwiDiTib — There is almost always
some accompanying retmitis with all cases of
144
CHOROID, DISEASES OF
plastic choroiditis. It is unnecessary to add
anything to what was said under that heading
SCIRBOTICO-CHOBOIDIT&, OR MYOPIC CHOBOIDITI*
— This is rather of the nature of an atrophic
condition of choroid than a true inflammation,
and will be reform! to under " Myopia "
TUBERCULOUS DI^EA^K may affect the choroid
in throe ways, which differ in ophthalmoscopic
signs, prognosis, and treatment
(a) Tubetrulout DtMemnuited Chmouhtis —
This form of chronic inflammation of the choroid
is very similar to the syphilitic variety, and is,
according to some authorities, as common It
is with difficulty distinguished, but the patches
are smaller and slightly laised Just as in the
syphilitic form, degeneration takes place with
thoroidal atiophy, the process being, however,
slower Its treatment is unsatisfaetoiy ; befoie
atrophic changes have set in mercurial inunc-
tion may help absorption of the exudation, and
phosphates or arsemates with cod -In or oil
should be piescubed by the mouth The
prognosis is not so good as in the syphilitic
variety
(b) Mil tat y Tulieitulov* of the Choroid occu-
pies the region of the chono-capillaiis and the
vascular layei, and is quite behind the uvea
It is most commonly found in cases of acute
miliary tuberculosis, but it may be piesent in all
forms and stages of tuberculous disease
Ophthalmoscopically it appeals as a gicyish
homisphei ual eminence vaiymg fiom 3 mm to
1 mm m diamotei, and may be even smallci
One or seveial of these fust appear m the
macular region, and are afteiwaids followed by
others in the neighborhood The youngest
tubercles aic \ery small, the oldest are the
largest, and aio somewhat white at the centre
The ophtlmlmoscopic signs are very similar to
those of disseminated choioiditis, though the
t\vo conditions are not likely to be mistaken
owing to the different general conditions The
patches are mnie idised, raiely pigmented, more
clearly defined, and less brilliantly white In
the foim that occurs in acute geueial tuber-
culosis they appeal as a mlo only ashoit time
befoio death P.ipilhtis is a frequent accom-
panying symptom Both eyes ai e neai ly al\v ays
affected
Micioscopically each patch shows the typical
stiucture of tubeicle, though the specific bacilli
are not always to be found
In cases of acute tuberculous disease \\hore
there are typhoid symptoms, and m tuberculous
meningitis where the diagnosis is not always
easy, the detection of tubercles of the choroid
is of great assistance in clearing up the case,
although the absence of ehoroidal tubeicle does
not piovo the absence of tuboiculous disease m
other organs
(c) Tubeicttloui Turnout of tlie Ckoroid — This
condition is piobably always secondary to tuber-
culous disease elsewhere, though this cannot
always be proved In early stages, a retinal
detachment, less defined than the detachment
due to choroidal sarcoma, will bo the only sign.
As growth takes place glaucomatous symptoms
rarely occur, the coats of the globe rapidly
giving way with the formation of a staphyloma
and subsequent panophthalmitis It is doubt-
ful if gencial infection can occur, so enucleation
should be postponed till vision is lost The
growth is always umlatcial
GUMMA ot riuE Ciinmun is veiy rare It may
exist in conjunction with gumma of the ins or
ciliary body The diagnosis is necessarily
difficult, inasmuch as the vitreous is hazy and
the fundus cannot be seen It rests mainly on
the coiu'uirent syphilitic lesions, the history,
and the effect ot antisyphihtu treatment Sight
is usually greatly impaiied, but, if the condition
is attacked in time, almost perfect vision may be
regained
HARIOMA ot mi CiinKnjn is the commonest
uitia-ocular turnout of adult life, just as glioma
is the most irequeiit m infancy and early child-
hood
Etwioyy — No cause has been discoveied
There appeals to be no lelationsbip between it
and blows on the eyeball
Nymptomi — Saieoma of the choioid usually
begins m a mannei so insidious as to be un-
noticed e\en by the patient until the tumour
has attained a connuleiable si/e , c\en then it
is often discoveied at cidon tally Sometimes,
however, though rarely, the growth of the
sarcoma IN accompanied by local pains, phos-
phenes, etc
When seen tit an ently vfnf/e theie may be
nothing externally to attiuct notice In addi-
tion to the dimness of sight whuh may have
fiitit caused the patient to apply lot aduce, we
find that the visual field is defective, and, when
it is examined by means of the pei inieter, pie-
sonts a scotoma (oncsponding to the position oi
the turnout With the ophthalmoscope the out-
line ot the turnout can sometimes be seen to
toiin a rounded pi niumeiice, pushing the ictina
foiw.uda into the vitreous cavity In this early
stage inflammatory signs aie absent, and the
tension is normal or even slightly subnormal
At a latet sttu/e the presence of the tumour IH
accompanied by a distinct increase in the tension
of the globe, and the eye presents other symp-
toms of glaucoma The antenoi ciliary vessels
aie congested, the coniea becomes hazy and
inoto 01 less anaesthetic The anterior chamber
gradually becomes shallow The nis is some-
times subacutely inflamed, and foims posterior
adhesions (synec/iice) to the capsule of the lens,
which render the pupil irregular Not infre-
quently the ins is atrophied, and it may be
detached at that part of its pcnpheiy which
corresponds to the position of the tumour The
vitreous also is frequently rendered cloudy by
the presence of opacities The vision has gradu-
CHOROID, DISEASES OF
145
ally become worse, and is now reduced to bare
perception of light When the disease has
progressed so as to destroy vision thcio is fre-
quently considerable pain m the ciliary region
and lachrymation, more seveio than in true
glaucoma
In the thnd staye the tension of the globe is
suddenly reduced, signifying that the Hclcrotic
has given way, and the glaucomatous Kymptoms
are relieved. The growth, however, now rapidly
extends and mfiltiates all the sunoundmg
structures
PatJuology. — Sarcoma of the choiuid may be
divided into the iollowing varieties —
A Leuco - sarcoma — («) Spindle-celled , (6)
round-celled, (c) mixed-celled
11 Melano - sarcoma — (a) spindle -celled , (b)
round-celled, (t) mixed-celled
C Intervening grades of pigmentation
Of these, spindle-celled mclauo-saicoma is the
commonest Letico-Harcoma is found in about
one case in e\eiy eight or nine, but even then
a few pigment - containing cells are present
When the growth is white the cells are usually
of the round vanety, and it appeals probable
that this foim starts from the non-pigmcnted
chono-capillary layer, while the melanotic form
has its origin in the deepei pigmented layers
The turnouts usually are firm , they gener-
ally con tun some blood-vessels, and sometimes
aic vry vascular , the walls of the blood-vessels
are composed of snrcomatous elements They
have an even and smooth convex surface so
long as the lamina vitiea remains intact When
they peiforatc this membrane they gro\v more
lapidly, become hour-glass in shape, and present
an irregular granul.u surface Sometimes theie
is also effusion of serum or blood beneath the
retina They may increase so as to fill the
\vhole globe and distend its \valls before invad-
ing the extia-ocular tissues , but m many cases
the tissues outside the scleiotic aio affected by
the new giowth, whilst the tumour within the
globe is quite small, in these cases the cells
pass to the outside by means of the sheaths of
the blood-vessels, which aie seen to be thickened
and altered by the presence of cells similar in
character to those of the tumour
The neighbouring lymphatic glands aio not
affected, but secondary sarcoma is liable to be
set up elsewhere by a process of embolism, the
colls being conducted from the primary source
by the blood-current The liver is the organ
usually first affected
DUKJIWWS — It is obvious how important an
early diagnosis is, but this is often extremely
difficult In the eaily stage there is always
groat doubt, whether the ophthalmoscopic ap-
pearance of the retina is due to a simple
detachment from subretmal effusion or to a
sarcomatous growth m the choroid When the
latter is the case the detached retina may le-
tain some colour or be pigmented , it may occur
at any part of the f uudus, and it does not flap
about when the eye is moved In simple de-
tachment the detached portion is bluish white,
usually occurs at the lower segment of the
fund us, and may flap about freely when the
eye is moved Occasionally a vascular network
of the sarcomatous growth can be detected
thiough the letma In anjr case of extensive
detachment occurring in one eye only, and
when there has Iwcn no myopia or history oi
injury, we must suspect sarcoma of the choioid
In the stage of increased tension sarcoma of
the choroid may easily be mistaken for acute
primary glaucoma If the fundiw can be seen
theie is usually no difficulty , but if this is im-
possible, the diagnosis must be made from the
history of the case, whether any symptoms of
glaucoma had pieviously existed, and by the
condition of the visu.il held and the projection
of light An impoitant point in the history is
the relation between the onset of pain and the
loss of acuity of vision In primary glaucoma
the two are almost synchronous, whereas in
choroidal sarcoma the sight in most cases has
been giadually getting woise previous to the
glaucomatous symptoms
Cowrie and I'mgno&u — If left alone the
disease usually takes some years to run through
all its stages, the end being always fatal, the
patient dying geneially from extension into the
brain or from metastasis In all cases, how-
ever early the diagnosis is made, the eye is lost,
and we can nevei piomise that there will be no
recurrence, local 01 general
Titatment — Ktiucleatiou should be performed
as eaily as possible, togethei with excision of 4
01 5 mm of the optic nerve If the growth has
extended outside the globe the orbit should bo
emptied
CARIJVOMA ot rut: CUOKOID is very rare, and
is always secondaiy, usually to carcinoma of the
breast Death usually occurs within twelve
months.
CHOROWAL DEGI-^LRATION — Guttate choroiditts
of Tny is characterised by a number of yellowish-
white specks usually, though not necessarily, in
the maculai region They are probably spots
of colloidal degeneration of the choroid
Owficatwn of the ihoroid frequently follows
phthisis bulbi It may be extensive, a thin
plate being piesent on the inner or vitreous
pait of the choroid , or there may be merely
a few spicules of bone scattered throughout the
choroid
INJVRIF^ ru HIE CUOROID — Rupture of the
choroid is always the result of external violence,
such as a blow or a fall The accident is usually
followed by haemorrhage into the vicinity of the
wound, causing opacity of the vitreous After
a few days, as the blood becomes absorbed, we
can see a whitish line in the fundus, with a
little blood clinging to its edges. It is usually
curved, concentric with the edge of the disc
10
146
CHOROID, DISEASES OF
Subsequent to the rupture there is frequently
a tendency for masses of pigment to appear
round the exposed solera.
Concussion Chorotditts — Rupture of tho
choroid is often accompanied by macular
choroidal degeneration
Choroideremla.— Congenital absence
of choroid or of its epithelium
Choroid ItlS. See CHOROID, DISEASES OF
(Chorouhtis) , nee also AMBLYOPIA (Symjrtoms) ,
COLOUR VISION (Acquired, Chotoido-tetmitm) }
COIINEA (Interstitial fierahti*) , MENINGITIS,
EPIDEMIC CEREURO - SPINAL (Symptom*, Special
Sense*, Eyes) , SYPHILIS (Tertuvty, Eye, Choroid-
itis), SYPHILIS (Children, Bye, Choroiditis) ,
VISION, FIELD OF (Central Choioiditm)
ChoroldO - CyC I It 18. — Inflammation
affecting both the choroid and the ciliary body
See CHOROID, DISEASE* OF (fndo-ctiototdttw) ,
IBIS AND CILIAIU BODY (Cyrltti*) , GLAUCOMA
ChoroldO- IrltlS. —Inflammation ot both
choroid and ins See I HIS AND CILIARY BODY
(Iritis).
ChoroldO-retl n ItlS.— Inflammation of
the choroid, extending to the i ctma See CHOROID,
DISEASES OF (Jtetnw-Choroiditu)
Choroid PleXUS. See BRAIN, PHYSIO-
LOGY (Lymphatic Circulation) , HYDROCEPHALUS
(Etooloyy) , PHYSIOIOGY, NER\OUH SYSIEM
{Brain)
ChrOtn-. — In compound \vords chrom-, 01
chroma-, or chrome- meant* (( relating to colour,"
as in chr omatel 'opsis (colour-blmdnoss) , chronut-
tophobia (sensitiveness oi the eye to certain
colours) , chtomatosis (a morbid condition of tho
skin aa to pigmentation) , ckromocyte (a red
blood corpuscle), etc, as \icll as in the uouls
following
Chromatln. — The fibres of the cell
nucleus \t hich are stained by various dyes, and
which contain much nucleic acid, are composed
of a substance called chrornatm See PHYSIO-
LOGY, THE CELL (Nucleus)
ChromatolySlS.— Destruction of the
chromatin material m cells so that their stain-
ing power is lost (achromatoni) , this change
occurs in a nerve cell after the division of its
axon, and is usually temporary See PHYSIO-
LOGY, NERVOUS SYSTEM (Spinal Cord) ; INSANIT\,
PATHOLOG\ (C optical Nerve Cells).
ChromatOpSla. — That condition m
which all objects seem to be of a certain colour
(e.g giey), partial colour-blindness See
HYSTERIA (Sensory Disoidei s, Ocular Anaesthesia)
Chromaturla.— The state of abnormal
coloration of the urine
"Chrome HolOS.n — The cutaneous
ulcers occurring in workers in the bichromate
industry See TRADES, DANGEROUS ( Workers in
the Chemical Tiadts)
ChromidroslS.— The secretion of col-
oured perspiration, especially on the face and
eyelids See SKIN, DISEASES OF SWEAT AND
SEBACEOUS GLANDS (Chtonudrosis) , SKIN, PIG-
MENTAR\ AJ.FECTIONH OF (Spurious Piffmenta-
twns) , also EYELIDS, AFFECTIONS OF (Skin of
Lids, Chromtdrosit)
ChrOITI IS IT1. — Chronic chiomium poison-
ing occiu ring in workers in chemicals, and char-
ac tensed by ulceration of the nasal septum and
by " chrome holes " (7 v ) on the skin See also
TOXICOLOGY (Iintanti, Chiomium)
Chromium.— Theie aie two forms m
which chiomium occuis m the Pharmacopoeia
Chtomic acid, OOj, icadily soluble in \vater,
having a powei fully caustic action, and being
used as a disinfectant and doodoiaut Thcie is
an official Liquor Acidi Chiomici used some-
times as a caustic, the lotion employed as a
local application to ulcers, etc , has a* strength
ot 1 in 40 The othei official foim of chiomium
is Potassium bichi ornate (Potawii Btthromas,
KjOrO^UrOj) , it has an antiseptic and caustic
action, and has >>con used m cases of gastric
ulcer , it is best given (in doses of \th to T\yth of
a gram) in pill form compounded \vith kaolin, or
in capsules, foi it makes explosive compounds
See also TOXICOLOGY (Iiritttnts, Chiomium) ,
PHARMACOLOGY,
Chromocyto meter.— A coiom test
for estimating the amount of haemoglobin
present in the blood (Bizzozero) See HJSMO-
GLOBINOMETER (Ifaldane's)
ChrOITI Off ens. — Substances \vlnch do
not colour the fluid («• g the uiiuc) in \\lnch they
aie till it has stood some time, or till an oxidising
agent is added See PIGMENTS OF THE BODI AND
EXCRETA (Utootltn)
Ch romophanes. — The " coiommg
matters of tho inner segments of the cones of
the retina of animals \vherc they are held in
solution by a fat" (Syd Soc Lex.) See PIG-
MENTS OF THE BODY AND ExciiEfA (Lipochromes)
Chromophlle Substance. — A
material, generally in the foim of gianules,
staining markedly with aniline dyes, and exist-
ing in nerve cells and their dendritcs, but not
m the axon , Nissl's granules
Chrom Op roteld.— A simple protoid m
combination with a pigment (eg hemoglobin,
heemocyamn, etc ).
Chrom ops I a. See CHROMATOPSIA ; but
the name has been specially given to cases in
CHROMOPSIA
147
which on account of hypencsthesia of the retina
there are subjective sensations of light m the
form of white or coloured clouds (Hack Tuke)
Chromosomes.— The larger thieads
of chromatm material which form, during mitotic
cell division, \\hen the nuclear membrane dis-
appears
Chronic.— Long-continued, eg a linger-
ing illness , opposed to ACUTE (</ v )
Chronotropic Fibres.— The neive
fibres which affect the rate of contraction of the
heait (Engelmann) ,S'ee RVIHMOTRQPIC
Chrysaroblnum. — Chrysarobm is a
brownish yellow powder obtained from (loa
Powder (Araioba) by extracting \vith hot chloro-
form It contains chrysarobin (CJOH,,6Or) and
chrysophanic acid (Cr,Hs02(OH)2) " In the
form of the Uwjuenttim, Chtysarobini it is used
as a parasiticide m ringworm, etc , but it
stains the linen, and it is better, therefore, to
apply it a« a non-official pigment um (chrysarobm,
I part, solution of gutta-percha, 9 parts), whuh
does not stun It is too irritating to the gastro-
intestinal tract to give internally See DRUG
ERUFIIONS (Pujmtwtm y) t PHARMACOIOG\ , PRE-
SCRIBING , PSORIASIS (Local Treatment).
Chrysophan. — A bitter glucoside
obtained from rhubaib and senna (C1(,HlbOs),
under the action of acids it breaks up into sugar
and chryiop/tantc and (C]r>Hl()O4), a substance
known also as 7/tetr aiul, rhnlmibaii? and,
rhubarbatm, and ruminn By i educing chryso-
phanic acid, chrysarobm may be obtained
ChthonOflOSOlOgy.— Thescieucedeal-
mg with the geographical distubution of diseases
, the soil , vr'xro?, disease)
Chthonophagla.— Dnt-catmg
Ch U rriJS. $M CHARAS , CANNABIS INDICA
Chvostek's Symptom.— A state of
hj pei excitability of muscles and motor nerves,
so that mechanical stimulation, such as a tap,
will pioduce muscular contraction See TETANY
(Motor Symptoms)
Chylanffloma. — A lymphangioma,
occurring sometimes m the mucous membrane
of the small intestine and stomach
Chyle. — The milky-looking fluid which is
carried off from the small intestine (during
digestion) by the lactcals or lymphatics, a
variety of lymph containing 6 per cent of fat
See ASCITES (Character of Fluid), LYMPHATIC
SYSTEM, PHYSIOLOGY, PHYSIOLOGY, THE BLOOD
(Lymph)
ChyleCChyslS.— An excessive secretion
of chyle.
ChylOOele. — An accumulation of chyle
in the tunica vagmahs. See FILARIASIS (Patho-
genetic effects, Chylocele)
ChylOderma. — Enlargement of the
scrotum and inguinal glands with dilatation of
the lymphatics of the skin, which form vesicles
containing milky fluid in whiph filante can often
be found , lymph - scrotum. *SVc FILARIASIS
(Lymph-scrotum)
Chylopoiesls. — The formation of chyle
tiff DIGES HON (/nte»tinal Secretion) , Pm HIOLOGI ,
BLOOD (Lymph)
Chylothorax. — An accumulation of
chyle in the thoracic cavity, ey from rupture
of the thoracic duct
ChylOUS ASClteS.— The piesence of
chylous fluid in the peritoneal cavity from
rupture or blocking of the thoracic duct or
lactedls »SV« A.SCITES (Causation)
Chyluria.— A milky or chylous condition
of the m me, usually due to the presence of
filarue in the blood See FILAIUAHIS (Pathogenic
effects, Chi/lm ta) , URINE, PATHOLOGICAL CHANGES
(Lipw la and Chyluria)
Chyme.— The food after it has been sub-
jected to gastric digestion and before it has been
acted on by the bile, the pancreatic, or the
intestinal secictions Xee DIGESTION AND META-
uouhM (Gastric) , PHYSIOLOGY, FOOD AND DIGES-
TION (Stomach)
ChyiYIOSln. — A ferment or cn/ymc which
coagulates albumin, ey the casein of milk,
rcnnm, pepsin
CiblSltome. — An mstiument foi lacerat-
ing the capsule of the lens in the early part of
the cataiact operation (Petit-Railel) , the name
is derived from M/Juris, <i pouch, and ropj,
section (tiyd »S'or Lex )
Cicatrices.
DEFINITION AND STRUCTURE 147
PATHOLOGICAL CONDITIONS OF 148
KELOID 149
MALIGNANT DISEASE OF 150
tiee BURNS AND SCALDS (Treatment, Results of
Jiurns, etc.) , EYELIDS, AFFECTIONS OF (Entoopion
and Ectropion) , INTESTINE, DISEASES (Ulcers,
Cicatt nation*) , INTESTINES, SURGICAL AFFEC-
TIONS OF (Sti icturesftom Ulcers), LIVER, DISEASES
OF , SYPHILIS (Tertiary, Gummata, and Cicatrices),
MENSTRUATION AND ITS DISORDERS (Retention of
Menses, Vaqinal Atresia) , UTEUUS, MALFORMA-
TIONS OF (Stenosis)
CICATRICES or scars are new formations of con-
nective tissue which develop m place of losses
of substance
148
CICATRICES
Ordinarily, however, the terms are applied to
superficial formations of "scar tissue" which
are covered with newly developed epidermis
A healthy cicatnx has a smooth, more or less
glossy surface. In its eailicr stages it is of a
pinkish colour, duo to the persisting vasculanty
of its connective tissue , later it Incomes white,
dense, and much less vascular It differs from
true skin in being less elastic and in possessing
no sin face fin rows, hair follicles, sebaceous 01
sweat glands The surface shows slight longi-
tudinal ridges, caused by contraction
The size of a scar depends on the amount of
normal tissue which has to be replaced
A When healing takes place by first inten-
tion, the resulting cicatnx is "lineai" and in
time it tends to become less and loss apparent
Under the microscope a transverse section
shows a nairow, non-vascular band of connective
tissue covered by epithelium, and with its ele-
ments arranged parallel to the surface
B When healing takes place by verond inten-
tion, the resulting cicatnx has a more widespread
surface Clinically, its characters depend on the
nature of the preceding granulation tissue
Microscopically, the cicatm of a wound which
has healed by second intention shows on the
surface a thin covering of epidermis This
covering is indented from beneath by papillary
tufts, which are simply the organised vascular
tufts of the preceding granulation tissue They
contain no tactile end -organs, the connective
tissue forming them is denser and less vascular
than in the case of the papillae of normal skin,
and they tend in time to become more flattened
Below this is fibrous connective tissue, arranged
in interlacing bundles, more or less vascular,
and more or less cellular, according to the age
of the scar Unna states that elastic tissue may
in time be re-formed in the scar At the margin
of the cicatnx its structure rather rapidly merges
into that of the surrounding normal tissues
Cicatrices aie divided into three varieties —
1 Normal or flat cicatrices, whoso level is
the same as that of the surrounding skin
2 A trophic cicatrices, in which ovei -contrac-
tion of the fibrous tissue has taken place, and
the surface is retracted below the level of the
surrounding skin
3 Hypertrophic cicatrices, wheie in conse-
quence of over-reaction, or long continuance of
the healing process, an excess of scar tissue has
been formed, so that the level of the cicatm is
higher than that of the surrounding skin.
Treatment of such cicatrices is only necessary
when they cause disfigurement, particularly on
exposed surfaces. Measures directed towards
keeping up their vasculanty, such as massage ot
pamtint/ with iodine, tend to induce a degree of
resoiptiou, or if the surrounding skin is lax, the
scar may be excised and the edges accurately
apposed with the view of substituting a lineai
cicatnx.
PATHOLOGICAL CONJJIIIONS OF CICATRICES
1 WEAK CICATRICES aie thin, shining, red-
dish, easily wimklcd and cracked, prone to
break down and ulcerate in the centre, the
friction of the clothes being sufficient to cause
this
They result when the oiigmal wound has
IXMJII very extensive and contraction has l>oen
incomplete during the healing process Hence
they orciu after severe burns or scalds, par-
ticularly if these have affected the tissues
deeply , but a smaller cicatnx when it is
adherent to bone may also show a weak
tendency
Certain constitutional conditions, as tuber-
culosis (scrofula), andemia, syphilis, scorbutus,
conduce to the formation of weak cicatrices
The weakness may be due to defective granula-
tion, or defective epithelial formation (kera-
tmisation)
Treatment — Treat locally, as foi ulcers In
addition to topical applications, the pait must
be carefully protected tiom the slightest injury
and the general health attended to, ti eating
the constitutional condition if it can be made
out
If the wound has been extensive, there is less
chance of good cicatrisation, and a plastic opera-
tion is necessary Thieisch-giaftmg may riot
give a good result in such an ulcei, and it is
bcttci, after scraping or cutting away all the
unhealthy tissue, to transplant a piece of skin
from the ncighbouihood (vide " Skin-grafting ")
2 EXUBERANT, HYPERTROPHY, DEFORMED
CICATRICES — Cicatrices of lagged wounds, such
as are caused by glass, splinters of wood, or
nails, aie generally prominent and ugly The
scars of tuberculous ulceis aie extensive and
irregular Wounds which take a long time to
heal by granulation may develop a large hyper-
trophic cicatnx Tieatment is required only
\\hen the scar is on an exposed surface, and
then it is foi the removal of the disfigurement
caused
When the surrounding skin is tense, opera-
tive interference is inadmissible, though somo
improvement may be brought about by measures,
such as massage, painting with iodine, etc.,
dnccted to the increase of vasculanty in the
connective tissue , but if the skin be lax, the
scar may be completely dissected out, the edges
accurately apposed with buried catgut sutures,
and a linear cicatnx substituted for the hyper-
trophic one
3 CONTRACTING CICATRICES, CAUSING DE-
FORMITY —Such cicatrices may in themselves
bo quite healthy, but they cause conditions
which become pathological
(a) Simple contracting dcatrtsr — The amount
of contraction depends on the depth of the
original wound. When the wholo cutis has
been destroyed, the contraction is greatoi than
CICATRICES
149
when only the papillary layers or part of them
are destroyed
The cieatnx is broad , it is thin and parch-
ment-like, of a light colour, mottled on the
surface The surface is uneven, and marked
with ridges Such a cicatm may be been aftei
extensive burns of the front of the neck and
thorax, and causes dragging down of the jaw,
eversion of the lower lip, ami constant dribbling
of bain a, which is apt to cause superficial
ulceration of the sear If on the face, they
cause octropion or anchylosis of tbe ja\v, and
when in the neighbourhood of the natural
orifices have caused their distortion or partial
closure
Whon occurring in flexures Ihey tend to cause
adhesions in the angle, and the parts become
fiimly connected by a strong prominent cicatrix,
the so-called vicious Itrulle Examples of such
ucatiiccs aie seen in the axilla — connecting the
arm to the tiunk, in the bend ot the elbow,
causing persistent flexure, or in the hands and
feet, causing distortion or adhesion of the
digits
If possible, treatment should be begun early
in cicatrisation, bufoie contraction has taken
place, by splints and extension apparatus
If < icatrisatioii u, complete, tieatment usually
consists in dividing the cicatm completely,
either tiansverhely 01 in a V-shapcd manner,
stretching it and filling up the gap thus caused
by skin giafts In making the incision it is well
to lomember that important nerves and vessels
may be involved in or adherent to the cicatrix
Simple extension, compression, and massage of
the cicatrix 01 painting it with icxline have also
been recommended with the view of uureaung
vasculanty and promoting aksoiption, but such
measures are never wholly successful Hebra
recommends subcutaneous injection of a 15 per
cent alcoholic solution of thiosmamin, but ex-
perience of this remedy is limited
(b) In the deprewed, adherent MYM, treatment
consists in dividing the band of attachment, by
means of a tenetomo passed m from the edge,
and raising the scar Less active measures,
with a view to increasing the vasculanty and
promoting absorption, are never wholly suc-
cessful
When it results from a sciofulous (tuber-
culous) gland, Adam's operation (lit it Med
Jouttuil, 1876) may be employed After freeing
the cicatrix from the side, he passes two hare-lip
pins, at right angles to each other, under rt so
as to raise it After three days, dining which
the scar tissue has become swollen and succulent,
and the space beneath filled with blood clot, he
removes them The scar subsides to the level
of the skin without re-formmg adhesions
Cicatrices may also cause deformity by yield-
ing to pressure from beneath, as m those
following laparotomios, when ventral hernia
may result
4 PAINFUL CICATRICES — Pain may Ije pr esent
in any cicatrix, but is most common m those of
amputation wounds The pain is caused by
inclusion of the nerves m, or their adhesion to,
the cicatricial tissue Some authors say that
the pain is caused by neuritis dependent on
the contraction of the scar
Neuralgia of the Cirato i& — In this case the
pain, which is paroxysmal, is generally duo to
some constitutional condition affecting a cieatnx
in itself healthy It may persist in spite of
opei ative interference
Tieatment — Free adhesions in case of de-
pressed or adherent cicatrices If the cicatrix
1)0 small, excise it altogether and slide a flap
of skin over it If the cicatrix be extensive,
neuiotomy, neurectomy, or nerve - stretching
may be useful
Where there is no abrasion of the surface, in
the case of a small, painful cicutrix, ointment of
acomtme (1 gr to 51 ) is of use as a palliative ,
01, if bioad, it mav be protected by simple
plaster, or ernplastrum opn, or may be simply
covered with cotton-wool
5 DISCOLOURED CICATRICES — The cicatrices
from old chrome and varicose ulceis have al wax s
a permanent brown colour Large sciofulous
cicatrices have an unsightly h\id tint
Foreign matter may be present, such as
uriconsumed grains of gunpowder in cases where
the injury has been caused by an explosion, or
in tattooing
Occasioned corneal opacities are due to the
presence of reduced silver, where the preceding
ulcer has been treated with silver rutiatc
These discolor ations occasionally require treat-
ment when on exposed surfaces
KEUIID, OR CIIELOIU
is a comparatively rare fibrous new growth
of the skin which usually develops in an old
cieatnx It was first described by Ahbert in
1810 Keloid was formerly divided into true
01 spontaneous and false or cicatricial keloid,
but this distinction is no longer generally held,
as most of those termed spontaneous probably
(lev elop m minute scars, such as are left by acne
pustules Histologically they are identical
The etiology is practically unknown Its
growth seems to be dependent on some con-
stitutional state , for example, it is very
frequently associated with the tuberculous
diathesis It is more common m negroes than
m white men, and it may occur in more than
one member of the same family All grades of
society arc liable to it, both sexes, all parts of
the body, and it may occur at almost all periods
of life Morrow states that in his experience it
is more common between 30 and 50 years
Keloid often develops m scars which have
been unduly irritated, and it may develop in a
healthy scar long after this is fully formed
150
CICATRICES
In individuals liable to it, it develops after
such slight operations as piercing the ear for
ear-rings, extirpation of warts, cauterisation, or
alter leech and insect bites, or on the sites of
acne pustules. It may be multiple, as in a case
of Schwimmer's quoted by Morrow, in which
105 tumours were counted
Keloid is a scar-like growth, usually circum-
scribed and isolated It may occur as a rounded,
firm, pinkish elevation, with irregular or smooth
surface, and on section creaks under the knife
Often fiom the central mass claw-like processes
extend in the surrounding skin As a mle it
has the shape of the scar from which it has
developed, but occasionally a part only of the
scar undergoes the morbid change
Neumann, Warren, and Kaposi have described
the microscopical appeal anco
Connective tissue begins to develop from the
walls of the small blood-vessels of the cutis In
this way dense fibrous tissue is formed under
the epithelium, the bundles being placed chiefly
parallel to the surface, though a few small
bundles are perpendicular to it This is more
vascular than true scar tissue. The epithelium
is thinned ovei it, and the geimmal layer of the
rete mucosum becomes irregular The growing
part of the tumour is more cellular than the
central older part, which may become very him,
dense, and hollowed on the surface Frequently
dilated veins course over it
The tendency to recurrence is explained by
the development of spmdio colls in the advon-
titia of the vessels — a condition often extend-
ing to some distance from the edge of the
tumour
Koloid is usually confined to the dermis,
leaving the papillary layers intact If of a
large size it may cause deformity by contrac-
tion It may project any distance from a line
to J or £ inch above the level of the surrounding
skin
Clinically, kcloid starts near the edge of the
scar, it may cause no symptoms other than
a sense of weight There arc usually, how-
ever, subjective symptoms such as itching
or sensitiveness on pressure, pain is not
common , ulcoration and haemorrhage may take
place.
It may develop in a few weeks, or at most
a few months, after the exciting cause Its
natural tendency, as of all young fibrous tissue,
is to contract after a time and atrophy.
According to Neumann keloid never de-
velops malignancy
Diagnose — From hypertrophic cicatnx by
its outline, elevation, consistence, colour, and
presence of itching 01 pain, and by the tendency
of the latter to become stationary
The diagnosis from scleroderma and Addison's
keloid (morpoca) will be discussed under " Solera-
derma," and from rhinoscloroma, under " Skin,
Benign Tumours *
Treatment. — Local treatment is directed to
wards decreasing the vascularity of the tumour
Applications like collodion (not flexile), either
alone or containing lead acetate, a drachm to
five drachms of collodion, are useful Com-
presses, strapping, elastic pressure, must be
applied with caution, as they are apt to causo
sloughing, and are only applicable when the
keloid is circumscribed, painless, not greatly
projecting, and resting on a bony surface
They are especially contra-indicated in diabetics
and delicate patients Multiple scarifications
are of doubtful benefit, either alone or followed
by mercurial ointments In a few cases strong
salicylic acid plasters 10 to 20 or 25 per cent
have been successful.
Itching is best relieved by regulation of the
diet, by an occasional saline purgative, Fow ler's
liquor aisenicahs, liquor potass&o in largo doses,
or by frequent tepid bathing, either simple or
with addition of carbonate of soda or potash,
common salt or bran
Pain is relieved by ointments of camphor and
chloial
Surgical interfeiencc by excinion is only
justifiable when the smgeon is reasonably
certain that he can improve the appliance of
the part by substituting a linear scai for the
keloid, 01 at least of lessening its size
Tendency to recurrence is very maiked, and
the recurrence is often more exuberant than the
original growth In most cases it is beat to
leave well alone, and employ only palliative and
constitutional remedies
Excision may be contemplated whoii the
keloid is very unsightly and \vheie them is
plenty of free skin surrounding, so that the
edges of the wound can be readily apposed
without tension The giowth must be com-
pletely removed, and bmicd sutures used,
approximation being assisted by strips of gauze
hxed to the skin with collodion Everything
must be done under stuct asepsis
Constitutional Treatment — Cod -liver oil,
iodide of non, nourishing diet, are of use where
tuberculosis is suspected, mcrcuiy and the
iodides m syphilis Good results have been
obtained in the treatment by sea bathing
MALIGNANT DISEASES OF CICATRICES — Sarco-
mata develop rarely in cicatrices More com-
monly, but still rarely, epithehomata occur
They may develop at any period after the
cicatnx has formed One case is on record
where epithchoma developed in an old lady in
the bear of a burn which she received when a
child of four years
Epithehoma develops very slowly in the
cicatnx, and may not involve neighbouring
glands until it grows beyond the cicatnx into
normal tissue, in which it develops more
rapidly.
Treatment consists in early and complete
excision
CIECHOCINCK
151
ClechOCl nek. See BALNEOLOGY (Russia).
ClffarettOB. — Drugs, such as stramonium,
may be inhaled in the form of cigarettes, as in
asthma See PRESCRIBING, ASTHMA (Treat-
ment), etc
Cilia. — The hair- like processes from the
free surfaces of colls (e<j epithelial cells), which
move to and fro with a vibratory motion See
PARASITES, PROTOZOA, (Ciliata) , PHYSIOLOGY,
TISSUES (Epithelium, Ciliated), also, the eye-
lashes See EYELIDH, AFIKCTIONH OF
Ciliary Body. See IRIS AND CILIARY
BODY (Anatomy, Physiology, Diseases) , PHYSIO-
IOGY, SENSES (Vision, Ciliaiy Ptocewes, Ciliary
Muscle) See also ACCOMMODATION (Spasm of) ,
DIPHTHERIA (Complications, Patalysi* of Ciliary
Muscles); RETINA AND OPTIC NERVE (Congenital
e* in Vessels, Ctlio-ietinal Artety)
CIIIOSlS. — A spasmodic tiemblmg of the
eyelids, or the sensation of such , the feeling of
" live blood "
.— A bug, the bed bug (Cimex
tectulanus) may by its bite produce a great deal
of cutaneous iea<tion (like urticaria), but borne
individuals seem to be immune to its poison
Ste STINGING INSECTS
Cimlclfug-ae RhlZOma.— The rhiz-
ome of the Cimicifuya tacemota (perhaps bettor
known as Activa racemow) is used as a bittei,
and also, to some extent, as a heart tonic
(raising the artenal tension) , theie are two
ofhcial pi cparatioiiH, the Ertiattum Cimmfnycp
Liquidum (dose, 5 to 30 m ), and the Tiiuctu.ro.
Ctmmfiifjve (dose, ^ to 1 fl dr ) , it ib employed
in the treatment of chorea, rheumatism, dys-
pepsia, and dybmenorihoca , the name (cimici-
fuga) liteially means " putting bugs to flight,"
and the umicifuga racemosa is popularly termed
bugbane
Clmlez. See TiiEUAi'KUiics, HEALTH RE-
HORIH (Kivieta, ytte)
Cinchona. See QUININE, ALKALOIDS,
PHARMACOLOGY, PRESCRIBING, MALARIA, etc
Clnchonlne.— An alkaloid (C19HaN,O)
obtained from cinchona, ibomcnc with anchom-
dtne and with ctnthomcine Nee QUININE, etc
Clnchonlsm. — Poisonous symptoms
(tinnitus annum, deafness, impairment of vision,
headache, dilatation of pupils, etc ) due to use
of quinine in large doses or to an idiosyncrasy
of the individual
"Cinder-sifting Movement."—
In cases of movable or floating kidney, a tilting
movement of the organ may take place in the
plane of the loins by which the convex border
of the kidney turns forwards, this is termed
the " cmder-sif ting movement" See KIDNEY,
SURGICAL AFFECTIONS (Movable and Floating
Cinematograph. " A contrivance
by which a series of instantaneous photographs
taken m rapid succession can be projected on a
screen with similar rapidity, so as to give a
life-like reproduction of tkb original moving
scene " (Murray, N E.D ) , the cinematographic
(or kmematographic) method has been used for
the representation of surgical operations and of
medical symptoms (ataxia gait, etc ), and may
yet be employed for embryological processes,
etc
ClnOS (therapy. The treatment of
diseases by means of natural or artificial move-
ments of the body, eg by Klapp's four-footed
pi egression movements in spinal curvature, etc
Cinnabar.— Red sulphide of mercury
occurring as an ore in Spam, California, Peru,
and elsewhere , from it mercury is obtained by
roasting and distilling
Clnnamlc Acid.— An acid (C9H8o,)
obtained from the lulsams of tolu and Peru, or
from storax, it can IHJ artificially made by
heating 2 parts of benzaldehyde with 3 of
acetic anhydride and 1 of sodium acetate
(Perkin's icaction) From it cmnamene (C8H8),
a volatile oil, can be got, while from <innamic
aldehyde (C9H8O) can be obtained cinnamenyl-
auylic acid (CnH10O2) and cinnamenylangelic
acid (C1SJI1402) Cinnamein is an oil (C9H7O2
C7H7) contained m the balsams of tolu and
Peru, and obtained artificially by heating
sodium cinnamatu with ben/yl chloride, it is
benzyl cmnamate See IMMUNITY (Treatment of
Tulieiculosis by annamu acid), LUNG, TUBER-
CULOSIS OF (Treatment, Sjtfiijic)
Cinnamon. The dried inner bark of
Cinnamomum zeylamcum is official, and is known
as Cmnamomi Cortex , it has a fragrant odour,
and the well-known taste It contains the
oihcial oil (Oleum Ctnnamomi), tannin, sugar,
and gum, it is contained in various powders
and tinctures, and its dose is fiom 10 to 20
grains The official pieparations of the cortex
are the A qua Cinnamomt (dose, 1 to 2 fl oz ),
the Pulvi* Ctnnamomi Cmnpovitus (dose, 10 to
40 grains), and the Timtwa Cinnanumn (dose,
J to 1 fl dr ) , the Aqua and the Pulviv are con-
tained in various other pharmaceutical prepara-
tions The Oleum Cmnamomi consists chiefly
of cinnamic aldehyde (C!tfH80), a terpeue, and
eugenol (C10H120.j) , it is given in doses of J to
3 m , and its official pieparation, the Spmtus
Ctnnamomi, has a dose of 5 to 20 m Cinnamon
is used foi flavouring medicines , the bark has
also astringent properties, and the oil is a
stomachic and carminative. See also PHARMA-
COLOGY , PRESCRIBING , etc
152
CION
. — In compound words don- (Gr. KUOV)
means the uvula, as in nonoptoats, relaxation of
the uvula, ctonotomy, cutting the uvula, ciono-
tome, etc.
Olrclnate. -Rounded.
Olrcle Of Haller.— A vascular plexus
on the sclerotic, near the entiancc of the optic
nerve, formed by branches of the shoit ciliary
arteries, and named on this account circulus
artertosus Halleri , the circulus venotuH Hallcii,
or circulus vcnosus niammoe, in that formed by
the veins round the nipple
Circle of Masca^ne.— The name
given to the circular ariangement of capillaries
in the region of the zonulo of Zinn in the fwtus
Circle Of Willie.— The ciicuUr ariange-
ment of ai tones at the base of the brain (CM culm
arter torus Willwi), into the composition of which
enter the anterior and po&teuor cerebral and the
anterior and posterior communicating arteries
•See BRAIN, PHYSIOLOGY (Blood Supply)
Circular Insanity.— insamtv m \\hu h
a dull and depressed stage alternate s with one of
excitement
Circulation, tfee HEART, M\ OCA RDIIM,
AND ENDOCARDIUM, AIITBRIEH, DISEAMH OF,
CAPILLARIES, DISEASES UP, VEINS, DISEASES or
*SVw also ANEUKYSM , CHILDREN, CLINICAL EX-
AMINATION, PHYSIOLOGY, CIRCULATION, FOTUS
AND OVUM, DBVEI oi'MENT (Frvtal Cttntlafion,
Plaeental Circulation) , LYMPHATIC SYSTEM ,
PREGNANCY, PHYSIOLOGY (Chtmt/ei in Cttni/tt-
tlOn) , PREONAItCY, Al-'I ECTIONS AND COMPLICA-
TIONS (Catdto-Vavcular) , PULSE
Circumcision.
INTRODUCTORY HISTORICAL REFERENCES 152
INDICATIONS FOR OPERATINE MEASURES 152
DORSAL INCISION AND CIRCUMCISION 153
AFTER-TREATMENT AM> MODIFICATIONS 153
Sre olio VENEREAL DISEASE (tioft tfotes, Com-
pltcntumiiPhymom) , MK'IURITION (Inrontmcnic,
Detention), SPERMATOHRIKEA, URFTHRA, DISEASES
(Go)ioy > hoea, Comit/uation*, Phymtnw)
CIRCUMCISION is the operation for the removal
of the ptcpuce m its \\hole circumference Its
origin is obscure As ,i religious oidmance it
dates from the time of Abiah«im, but there are
proofs of an earlier Egyptian origin, while it was
undoubtedly practised in early times in Central
America, New Zealand, and the South Sea
Islands At the present day it is not only a
Jewish ritual porfoimed in infancy, but is cus-
tomary at puberty among Mohammedans, and
pro\ails in some parts of Central Africa
Apart from the question of religion and custom,
one may say, generally, that circumcision is indi-
cated wheie there is a condition of phymosis,
that is, such a narrowing of the prcpucial orifice
where the cutaneous and mucous membranes
meet, that retraction and reposition are difficult
or impossible. Difficulty m retracting the pre-
puce from epithelial adhesions to the glans is
normal at biith, and is not phymosis, and only
becomes so when natural or artificial means fail
to relieve the condition Operation is, theicfore,
only indicated \\hcn the normal process of re-
traction is delayed, and the orifice narrowed by
slight recurring attacks of balanoposthitis, and
more especially if complications anse which ex-
perience has proved to depend upon this condi-
tion The phymo&is may bo partial or complete
hypot trophic when the outer layei of the picpuce
is elongated , atiophic uhen tightly stretched
over the glans, inflammatory, wdematous, or
senile
The complications arising fiom phymosis aic
many they may take the fmm of urinary
tioubles, local inflammation and irntation, a
frequent combustion of the t>\o, and mal-
developmcnt ol the penis and gluis Of unnary
tioubles thete may be frequent} of mictmition,
straining and pain, cncuresis, ictontion, incon-
tinence, and o\erilo\v, dilatation of the bladder,
meters, and kidneys, \vith, as a ( onscquence, pio-
lapsus am, henna, htcmatuiia, m.i'inia, cystitis,
and stone Fiom local inflammation and imta-
tion aiise pain, swelling, oedema, muco-piiiulent
disch.nge>\ ith increase of the phymosis, ct ections,
mastuit)atum, seminal emissions, and other dis-
turbances ot the sexual functions, loading to
nervous tioubles, gastialgia, palpitation, hypo-
chondnasis, and it is even said simulated or teal
disease of the hip-joint, epilepsy, and biuin affec-
tions A combination of the t\vo naturally
aggiavates both, \vhile later in life maldevelop-
nient of the penis and glans, dithculties in coitus,
and the liability to venoieal disease and epi-
thehoma have to be considered Although all
conditions of true phymosis aic ically acquired,
as proper treatment in iniancy would have pre-
vented them, still for convenience, those occur-
ring in childiun whose foieskins ha\e ncvci been
retracted aie teimerl congemttil, while those
which appeal later in life, wheio the picpuce
has pieMously been easily retracted, arc called
Acquired Atqimed phymosis can only occur
when the piepucc is long, as it normally is in
33 per cent of adults The causes are usually
mflammatoiy, from gonorrhoea, chancies, ec/ema,
or herpes, but senile phymosis depends on
atiophy of the glans and limb of the penis, with
chronic irntntion
Should one or several of these conditions exist,
the next question to consider is when is operative
interference necessary, and legaiding this the
most varied views prevail
According to some, every long prepuce, whether
it can be letracted or not, demands operation, as
it may at a subsequent date lead to trouble The
other view is, that, as in the majority of cases,
CIRCUMCISION
153
even when in childhood, there is a slight stenosis
of the orifice, this condition disappears naturally
with growth and suitable treatment, it is always
wise to wait until complications anse, and to
make sure that these depend on the condition
of the prepuce before interfering
Of these two views the latter certainly appears
to be the moie sensible
It is a safe rule, therefore, that all conditions
of phyniOHis, in which retraction and reposition
are difficult or impossible, and which give use
+o symptoms, should be subjected to operation
The operation, whatever its natuic, should be
thorough, and lead to a sufti< lent and peimancnt
widening of thi1 prepucial orifice, with complete
separation of adhesions, partial operations, such
as insufficient doisal incision, frequently causing
inciensod phymosis through ucutnsatioii The
form of operation to be prefeired \anes, depend-
ing UIKMI which variety of phymosis is piesent
A In the ah opine form, when the piepuce is
stie tehed over the glaiw, and the1 outer Liyoi
docs not project, a dorsal incision is usually
sufficient
The patient having been piepaicd, a gencial
untcsthetic is .idnuinstered, though local anes-
thesia, such as that pi o< lined by the local injec-
tion of cocaine, may m exceptional cases bo
employed. In cases where masturbation has
been practised, it is iccommended by some that
no amesthctic should be used, the moral effect
of the pain being supposed to have a detenent
influence
In youths and adults a led mbber cathetei
should be tied round the root of the penia to
praont luvmorrhage , m infants this is incon-
venient and unnecessaiy
Klaboi ate disinfection of the sunounding paits
may be dispensed with, the penis being drawn
thiough a small hole in the cento c of a piece of
lint, stenhsed or moistened with warm 1 111 10
carbolic solution, and the sui rounding paits
covcied with sterilised towels
The penis being fixed, and the foreskin himly
retracted \\ith the left hand, a grooved dnectoi
is carefully introduced between the piepiue and
glans on the doisal aspect, and along this the
blunt blade of a small pan of scissois is passed
as fai baek as possible, and the piepuce dnided
exactly m the middle line The edges at once
gape, so as to foim an almost tiansxersc incision,
the inner layci lx?mg divided half-\vay uj>, the
outei layei somewhat higher By fuithei
traction on the skin of the penis, the outer layer
is drawn back as far as possible, and from the
angle of the inner layer a small tnangular flap
is cut with its base at the corona, and its edges
meeting at an angle of 60°, its length being
about half an inch in the adult and half that in
infants Irregularities of the edges of the inner
layer are removed with scissors, and the angular
extremities of the first cut rounded off Any
bleeding points having been twisted or ligatured,
Host's Modification
all adhesions between the prepuce and glans are
separated, slight ones by means of a blunt probe,
those that are firmer are cleared all round and
then divided close to the gUns, HO as to wound
the inner layer of the piepuce
as little as possible, and thus
prevent a-dcma, if neffssaiv,
any laigcr wound of thcmnei
layer is closed with a fine cat-
gut suture
The intcnoi of the piepuce
is then cleaned vith a 1
to 40 carbolic lotion to re-
inoM1 smtgma, and the wounds
sutuied "This is best done with a continuous
MI tun of fine catgut so as not to require sub-
sequent removal One <ommenccs by adj listing
tht ipo\' of the little triangular flap of the
inner layer into the angle of the wound n the
outoi li\cr This method is recommended by
Hewer as forming a skm edge at the a]K>\ of the
incision, and thus piovcntmg the lehealmg of
the original wound, with the formation of a
firm, innno^ iblc cicati i\, 01 even a iccurrence
of the phymosis
Local aftei -treatment consists in keeping the
pait .is mud) at rest and as aseptic as possible.
A good method consists ot dusting on a little
powdeied crystallised lodoform, and sui round-
ing the part with a naiiow stnp of several layers
of lodofoun gau/e, while ovei this a nairow car-
bolic gau/e band.igc is applied with moderate
himness up to the root ot the penw, this acting
as a kind of splint Care must be taken to pre-
vent the diessmg as fai as possible from
becoming soiled with mine It may be left on
for several days unless tho pait be painful, being
occ asionally moistened with weak carbolic oil if
it becomes wet Another method icconimeuded
is to keep the part co\ered with a small strip of
lint, kept moistened for the first twenty -four
houis with a mild antiseptic lotion , this is then
renewed and allowed to diy on
Complete primal y union is laiu in children,
but not uncommon in adults Any point that
remains unhealcd is best tieated by being
smeared with a little soft boracic ointment
The patient should be kept in bed for two days,
and then allow ed to he on a sofa, but he is not
to mo\o about for a week Biomide of potash
may be lequned in adults if elections be trouble-
some
n In the caw r>1 hyperttajt/ur j'hyniovn which
occurs so frequently in children, doisal incision
is unsatisfactory, leading to avlema and an
inelegant result Circumcision is, therefore, to
be prefeiied This operation, although it has
undeigonc mnumeiable modifications, differs
little in essentials from that originally per-
formed and still practised as a leligious rite by
the Jews
A point on the foreskin about a quaiter of an
inch in front of the corona is grasped obliquely
154
CIRCUMCISION
from above downwards, and from behind for-
wards with long dressing forceps, or other
special forceps, the obliquity making the result-
ing opening elliptical, and thus larger Care
must be taken that the glans is pushed back
and is not included in the grip of the forceps
The anterior portion of the prepuce in the grasp
of the forceps is then cut off by one sweep of a
sharp bistoury
The outei layer retracts to a considerable
extent, and care is, therefore, necessary not to
include too much in the forceps, otherwise the
limb of the penis is apt to be left devoid of
skin, this leading to delay in healing and sub-
sequent discomforts dunng erections
The inner layer still remains more or less
enclosing the glans, it is to be divided by
means of scissors in the mid-dot sal line almost
to the level of the corona, or Roser's triangular
flap may again be employed with advantage
The angles are then trimmed off up to the
frenum, leaving a small fringe of mucous mem-
brane surrounding the corona Bleeding having
been carefully arrested, the edges aie brought
together by means of a continuous or inter-
rupted fine catgut suture, the former being pre-
feiable, but in the case of infants sutures are
frequently unnecessary If the triangular flap
has been employed, it is \\ell for exactness of
adjustment to make a small mid-dorsal snip in
the outer layer to receive it The after-treat-
ment is as formerly described Should the
wound not heal by first intention, as is usually
the case at the fienum, warm baths and a mild
antiseptic ointment arc grateful and promote
healing
While these are the general principles upon
which the operations should be conducted, there
are, however, certain points to which furthci
attention must be directed
First, As to the employment of the clastic
band to pi event htcmorrhagc When this is
used, care
must be taken
before applica-
tion to mark
on the skin the
exact position
of the corona,
othciwisc one
is apt to re-
move either too much or too little of the pre-
puce
Second, The forceps haMng been applied, it is
usual to cut behind them Davics Collcy, how-
ever, Htrongly recommends that the incision
should be made in front of them, and the distal
portion of the prepuce having been made tense,
that the lower pait of the incision should be
made obliquely from behind forwards, so as to
form a triangular flap of the middle of the under
surface of the prepuce, which, he says, fits more
accurately into the triangular gap with its apex
DaviPH Collcy 8 Modification
at the stump of the frenum, which is formed on
removal of the inner layer
Third, When an elastic band has been em-
ployed in adults, pumary union is frequently
obtained and time saved by tying any obvious
vessel, suturing and applying the
dressing and bandage with moder-
ate pressure before removal of the
band The subsequent swelling
prevents further bleeding, but ex-
perience is necessary, as a too tight
application of the bandage before
removal of the elastic band may
cause such subsequent pressure as
may lead to slight sloughing of the edges of the
wound.
Lastly, As to the question of opeiation in the
case of gonorrhoea and inflamed hard, soft, and
phagedeme chancres, the fear of infection and
inflammation of the whole wound has frequently
prevented this fiom being done when otherwise
advisable, this, however, rarely occuis if the
raw surfaces are well washed with carbolic lotion,
any ulcerated surface not capable of removal
Ixnng nrst dried and then touched with fuming
nitric acid and lodoform rubbed in In the case
of great swelling and inflammation, a doisal
incision followed by disinfection and subsequent
lemoval of the ledundant flaps by means of
scissors, no sutures being employed, often gives
a better result than the more classical opeiation.
Cucumcision is usually devoid of risk, but
fatal cases have been lecoided fioiu ccllulitiH,
erysipelas, tetanus, and haemorrhage, while
infection fiom syphilis and tubercle are not
unknown as the result of ritual circumcision
among the Jews
ClrCUmdUSlon.— A variety of acupres-
sui e in which the pin is passed undei the vessel
and a wire loop ovci it
Clrcu induction. — A sweeping move-
ment of a limb whereby it is mode to describe a
cone with its apex at the proximal extiemity of
the limb
Cl rCU inferences. See LABOUR, PHYSIO-
LOGY (Foetal Head Circumferences).
Circumflex Nerve. See NERVES,
PERIPHERAL (Affection* of Special Nerves, Cii-
cumflejc)
Circumstantial Evidence.— Evi-
dence inferred from circumstances affording a
presumption but not a certain proof, opposed
to direct or positive See MEDICINE, FORENSIC
( Wounds ami Injuries).
ClrCUmval late. — Surrounded with a
rampart or raised border, eg a circumvallate
placenta, or one in which the foetal membranes
are attached at some distance from the peri-
phery, leaving a circular ridge all round
CIRRHOSIS
155
Cirrhosis* — The morbid change m an
organ or structure by which it becomes firmer
in consistence and, as a rule, smaller in size , it
is produced mainly by hypcrplasia of the con-
nective tissue of the organ or part Nee LIVER,
DISBASKS OF (Xiliaty Cm how, Poital Cm ho-
sis) , Luvos, PNKUMONOKONTOSIS (Patholoyical
Anatomy) , NEPHRITIS (Renal Cnthow)
ClrSOCele.— A varicose btate of the sper-
matic veins forming a swelling, a vancoeele,
the word is derived fiom ju/xros, a vanx, and
iciJAq, a swelling The condition may be com-
bined with hydrocele (ai
Clrsold Aneurysm. — A swelling
composed of enlarged and dilated artcncs Nee
ANFURYSM (Arterio-venous Intocumnmnicdttcmi)
ClrSOmphalOS.— A varicose condition
m and around the umbilicus , caput medusa)
ClrSOphthalmia. — Ophthalmia as-
sociated with a varicose condition of the con-
junctival blood-vessels
Clrsotomy.--The opeiation of excision
of vances
CiSSampelOS. — The dried wood of
Cistampefos jmreixi , official in the Indian and
Colonial Addendum to the It P , it is used in
cystitis and allied stateH , and it is gi\ en either
as the Dttoctum Ciivimjielt (dose, J to 2 11 o/ )
or as the Eitractum Ciwtmjieh Lt^intbtm (dose,
J to 2 fl di ) Nee AUROP\RUM
Cisterns*— Cisterns for stoung watci for
drinking pin poses should bo made of galvanised
iron or slate, not of lead (see TOXICOLOGY, Chi ante
Lead PotKHung) , they should bo ventilated,
should have an overflow pipe passing directly
into the open an, and should be easily accessible
for purposes of cleansing and inspecting , they
should hold about three days' supply of water,
a water-closet should have a small cistern of its
own (which may be made of lead), which should
empty completely each time, and be supplied from
the large cistern Nee WATER
Citarin. — An antipyretic and antirhou-
matic propaiation (J/mJ), being sodium anhy-
dromethylene citrate , used in doses of 8 to 20
giains m rheumatism, gout, neuralgia, etc
Citric Acid* — Acidum citricum
(H3CaH507 H20) exists in the juice of many
fruits, and is usually got from the lemon or
lime , it is contained in the xuccus linionis and
tyrupus limonii, and, as the citiate, in prepara-
tions of potash of iron and ammonium, and of
iron and quinine , it may be given as a refresh-
ing dnnk m fever (lemonade), or as an anti-
scorbutic (lime or lemon juice) , the dose of the
acid is 5 to 20 grams
Citrine Ointment. — Unguentum
hydrargyn rntratib See MERCURY.
ClttOSlS. — Depraved appetite , pica
Civet. — An unctuous substance with a
musk-like odour, obtained from the pouch lying
between the anus and the genital organs of tho
civet cat ( Viverra civet fa), a!hd foimerly used as
an antispasmodic
Civiale's Method of Internal
UrethrOtOmy. -Internal urethrotomy m
which a concealed knife is passed through the
structure, which is divided from behind for-
wards See URKIHRA, DISEASES OF (Internal
litethrotomy).
Civil Incapacity — Capacity
(Mental) for Civil Contract, etc.
— It may be stated geneially that a person
while insane is legally incapable of entering into
a con ti act , he is in the legal sense incapable of
giving the consent which is essential thereto.
Consequently he cannot enter into the contract
of marri.igc, nor can he execute a will More-
over, the management of his propeity may be
remo\ed entirely from his control
Whnt constitutes Legal Insanity — It is not
possible to fonnulate any criterion which would
be geneially applicable to the vaned cases
which arise To generalise in the matter would
be to mislead The question of insanity in such
cases is always the question of capacity intelli-
gently to do the particulai act The late Lord
President Inglis (in the Scottish case of Morri-
son, 18G2, 24 D at p 631) stud to the jury
" I am not going to gn e you any definition of
insanity , and I am not even going to define to
you w hat legal capacity is in a question of this
kind, because I may tell you at once that the
question whether a man is in such a state of
mind as to be capable of executing a deed of
this kind is a question of fact, and not of law
The test of his capacity to execute such a
settlement may bo very reasonably stated w ith
reference to tho natuio of tho settlement itself,
but it cannot possibly bo stated without refer-
ence to the settlement, because a man may have
strength of mind— power of intellect sufficient
to enable him to do one thing, to make one kind
of mental exoi tion — and yet he may be totally
incapable of making another A man may be
so far weakened m his mind as not to be able
to follow a difficult piocess of reasoning . .
and yet be perfect!} capable of making a simple
destination of his pioperty Tho two things
are totally different You can easily understand
that a man may not be capable of very long-
sustained mental exertion, and yet may be quite
capable, leasonably and fairly, of saying, I want
my estate to go to A B , or 1 want to disinherit
my heir and to leave my estate to an hospital.
That is not a very complex idea , and if a
156 CIVIL INCAPACITY— CAPACITY (MENTAL) FOR CIVIL CONTRACT, ETC.
person is capable of distinctly understanding what
it is that he is doing— is capable of expressing that
purpose in intelligible language, and is capable
of understanding the consequences and effects
of what he does — then he is capable of making
.such a settlement, and it is vain to go about
scientific definitions or anything of the kind"
{tee also Erskme, J., in Hanoood, 1840, 3 Moo
P. C. 282).
A deed disclosing no trace of incapacity or
insanity may nevertheless spnng fiom ,in insane
belief or delusion , but in establishing this to
the effect ot invalidating the deed, it is necessary
to piovo not merely the groundlessness of the
belief, but also the impossibility of its being
entertained hy any sane mind The existence
of a disordered belief upon borne extraneous
point, having no connection mth the subject
matter of a settlement, is not necessarily fatal to
the deed In a recent case the House of Lords
(reversing a judgment of the Scottish Courts)
held that these alleged facts, if estabhhhed, would
be sufficient to im alidate, on the ground of mental
incapacity, tho will of a testatoi who directed
the greater part of hi* large estate to be employed
in promoting total uhutmencc and preventing
the spicad of Jtomtin Catholicism It was
stated that upon these topics ho was subject to
insane delusions, and Irclieved that he had an
imperative duty to <le\ote hu» pecuniary ic-
sources to these objects in consequence of
commands which he had reurned fiom the
Deity by duect communication upon various
occasions , and these insane delusions dominated
his mind and mastered his judgment to such an
extent as to rendei him incapable of making a
reasonable and proper settlement of his estate
(Hope, 1898, 1 Fiasei, H L 1 , *r alw Lord
Penzance in Smith, 1867, L R 1 P & D
398)
It is necessary, then, that a testator should
have sufficient incmoiy to reciill the amount
and character of the projierty of which he is
possessed, and to remember the seveial pel sons
who may be said to have claims on him Along
with this memory, he must also have Ins judg-
ment reasonably clear and free, from moibid and
insane ideas, so us to be able to decide as to
these claims
The question of the mental capacity of a
person to entei into a particular contract 01 to
execute a particular will is frequently combined
with allegations of undue influence exercised by
those who benefit by this act The inquiry is
then, of course, pointedly directed to detei min-
ing whether he Mas facile, unduly liable to
persuasion, easily incited to wrong views and
feelings,--how far incapable of resisting pres-
sure
This incapacity to enter into civil contracts,
etc , exists only when and so long as the person
is insane If ho recovei s his sanity permanently,
or even temporarily, hu contracts and deeds
are valid A will executed in a lucid interval,
even by a person then confined in an asylum, is
perfectly valid (see Nisbet's Trs 1871, p. 9;
Macphcrson's Repot te, p 937) In such a case
the rationality of the document itself is regarded
as an important piece of evidence m favour of
sanity Tho burden of proof is shifted — that is
all Whereas a man is presumed sane until he
has been proved to be insane, a poison once
pwned to be insane is presumed to be insane
until his lecovery is pioved
Afowl hiwniti/ — It has been judicially laid
down in England (by Sir II .1 Fust m /Vere,
1846, 1 Hob E 11 pp 4i2, 446) that moral
insanity, unaccompanied by delusion, does not
invalidate a will Hut this tan scaicely be said
to bo recojrmsed in modem practice There
tan be little doubt that pi not of the insane
perversion of tho moral feelings would at least
be hold sufficient to invalidate a will (\et Wood
Konton on Lunacy, p 55)
Civilization. — The advance 01 develop
ment ot human society fiom a less to a moie
complicated condition of affairs, honi a lowei
to a highci grade of complexity , this is believed
(from a mcdiual standpoint) to mcicase the
frequency of msanitv and cancer, and to make
the process ot childbirth more dithcult See
INN AN in, ETIOLOGY
Cl VftaveCCh la. & e BALN KOT,OG Y (Italy,
Cladothrix Dlchotoma. -A species
of eladothiix, one of the genus of Sohi/oinycetes ,
the name is denved from jeAu&if, a branch, and
fyu£, haii, in reference to the pseiido-bianching
filaments of which the giowth is composed
tiee MICRO-OKOANISMS (Jfartrna, Xchizomycetei) ,
TEJCIII (Geneial Jinrtenoloy?/ of Moulh)
Clairvoyance. — The supposed state ot
mind of a person who can, it is said, see
mentally, when undei the influence ot animal
magnetism, places and poisons and things he
has never seen betoio, and give a collect de-
scription of thorn, this supposed power has
been alleged to be found to be of use in mediral
diagnosis
Clamp. — An mstiurnent for grasping and
compre&smg mmly structures and tissues, e.y
an artery to stop haemorrhage iSV« ANOKIO-
THIBE, etc
Clap. See UHKTIIUA, DISEASES OF (Gonor-
rhoea)
— The splashing sounds hoard
on auscultation over a dilated stomach
Clarke's Column. — The gioup of
neive cells lying at the inner angle of the
posterior horn of grey matter in the spinal
cord , tho columna vesicularis
CLARK'S PROCESS
157
Olark'S ProceM.— The metln
moving the hardness of water by adding
hydrated calcium oxide, which throws down the
caibonate of lime, which gradually subsides and
carries down suspended matters with it 1 oz
per 100 gallons is added for every degree of
temporary hardness, i e foi each grain per
gallon
ClaudlcatlOn. --Lameness, as in hip-
joint disease as an early symptom , also when
due to spasm, as in antenna and progressive
artcno-scleiosis, when it h<is been named clawli-
cation intermittent (/SVe SPASM )
ClaUStromanla.— The insane impulse
to take to " hninan bin rows " or enclosed spaces
,SW INSANITY, NATUUK AND SYMJMOMS (Impulse
awl
Claustrophobia.— Tlu fear of being
in a closed space, as < outlasted \\ith agoiapholna
('I v ), the fear of open hpaces *SVe IN HANI u,
NAIUKE AND SYMPTOMS (Impulse mid OlwsMon)
Claviceps Purpurea. *sve KR«HIT,
TOXICOLOGY (Etgotnm)
Clavicle. >SV«! UHACHIAL PLLXLS, Suiidi-
<AL A*FRCTIONS OK (TVwi and Contuwmi tn
Frtiitute of Clavule) , FRACTURES (Clavicle),
SHOULDER, DISEASES AND I v JURIES OP (Diifont
don ntul Fun tin e of ('la vide) , SHOULDER,
DISEASES A\D [NJUHIES (Excision of Clavicle),
Si A.RNO-CLAVICULAR JOINT( InjuneiawlDneaw) ,
TERATOLOGY (Alienee of Clavicle)
ClavtlS. — A coin 01 hardened projection
of the epidermis due to friction or intermittent
piessuie Nff CORNS, TVDES DORSALIS (Per-
toiating Ufttr of Foot)
ClaVUS HySterlCUS. — The painful
sensation as if a nail \\ere being driven into the
head, clou h ?/*ter uyue tiee HYSTERIA (Hyper-
wsthetia, Cephtilalgia)
Claw Hand. — The defonmty of the
hand ("mam en griffo") due to progiesaive
musLular atrophy, and brought about by con-
traction of the extensoi and ticxoi miibcles, and
atrophy of the thumb muscles, the intcrobsci,
and the lumbncales »SV» PAR \LYSIS (Ptogies-
nvt Muttulm Atiophy)
Cleft. — A fissure, groove, or narrow space
between t\\o projecting surfaces, e <j deft
palate, facial or irenal cleft, cleft of the nates,
vulvar cleft, cleft sternum, etc >SW CHEEK,
FISSURE OP, CHEST, DEFORMITIES OP (Cleft
Sternum) , EMBUYOLOGY (Btanchial Clefts),
PALATE (Clejt Palate), PAJ^TE (Congenital
Afaljormatumi of the Mouth)
CleldO-. — In compound words cletdo- signi-
fies relating to the clavicle, eg cfetdo-ftrachial,
1 itmg to the clavicle and the arm , cteido-
cervirat, relating to the clavicle and the neck ,
cletdo-hyoid, relating to the clavicle and the
hyoid bone , and deido-nuixtoiJ, yelatni-^ to the
clavicle and to the mastoiri procush of the
temporal bone
Cleldotomy.— Omsion of out' or lx>th
clavicles, an ac(,essory o|>erati<)ii m c<ises of
embiyulcia, in order h) dimmish the bisacromial
diameter of the fccta! trunk and so facilitate
dclrvery of the shoulders $ee LABOUR, OPERA-
TION (Cli tdotomy)
Cleptomania. >'** KLEPTOMANIA, IN-
SAMT^, NAIURE A\D SYMPTOMS (Impulse and
Of eiwtt)
Clevedon. — >SVe TIIEHAPEUTICH, HEALIU
RESORIS (England)
Clifton. Xec BALNEOLOGY (Gteat Butain,
Thenwd mul Huljtkwiiwl)
Climacteric.— -Relating to a chmacter
or cut ical period or year m human life (Or.
jcAt/m£, a ladder) , used also as a noun, climac-
teric signifies the critical period 01 year itself
The multiples of sc^en ha\e been considered to
be specially dangerous years, such as 7, 14, 21,
28, etc , and sometimes the multiples of nine
ha\c been included The <pand climacteric is
the sixty-third year (9x7 = 63) The term is
also used as synonymous \\ith "change of life,"
or the period (usually from 45 to 60) when
mensti nation ceases ("menopause") and the
ieinale generative organs atrophy tfee MEN-
hiiiUATioN AND ITS DISORDERS (The Afntopavsf) f
CLIMACTERIC IXbANITl , 1\SANIT\, NATURE AND
S\ML>IOMS (Etiologtcal Vatieties), MENOPAUSE,
UTERUS, ASSOCIATED INSANITY
Climacteric Insanity.
NEUROSIS OP THE CLIMACTERIC 157
INSANITY OF TUB CLIMACTERIC 159
CLINICAL FORMS OF CLIMACTERIC INSANITY 160
PROGNOSIS AND RESULTS 161
TREATMENT 161
ASVe alw INSANITY, NAIURE AND SYMPTOMS
(Etiolotfxal Vanehe*), MENOPAUSE, MENSTRUA-
nov AND ITS DISORDERS (The Menopause),
UTERUS, ASSOCIATED INSANITY
THE neuioses incident to the change of life
have not been studied with that care and
accuracy \v Inch the subject demands Although
it is an everyday experience in medical practice
to be called upon to undertake the treatment
of maladies, more or less severe and distressing,
complicating the menopause, the literature of
the subject is singularly scanty Dr Tilt (first
m 1853) published a book on The Change oj
Life in Health and Disease, which ran through
several editions, and still remains the only
English work of reference His observations
158
CLIMACTERIC INSANITY
still rank as authoritative, although his explana-
tions of facts must be regarded as obsolete
Various studies of affections of the menopause
have been made, e.y Dr Saundby (1885) pub-
lished certain observations on numbness of the
extremities occurring at the climacteric, quoting
Dr. Ormond and Dr Wharton Smkler Dr
Barnes (1890) and Dr Savage (1893) have
written of the neuroses of the menopause, and
Dr Merson (West Ridiny Atylum Repot t»,
1876) has given an elaborate summary of the
oases of climacteric insanity in that institution
during the four years prior to publication
These communications repiescnt .1 compara-
tively small volume of \\oik in relation to an
important epoch in the life-history of woman-
kind
It may be considered doubtful if there is <i
real analogous condition in men The momentous
epoch in a woman's life, when the menstrual
function ceases and hci general physical con-
dition undergoes a profound alteration, is bo
marked and is so determined by physiological
changes that it cannot fail to bo taken into
account, even in the most elementary consider a-
tion of epochal modifications At puberty the
child becomes a woman ni form <tnd fooling
The menstrual function is established and con-
tinues in periodic activity throughout sexual
life Any premature cessation of that function
is accompanied by symptoms of ill health, 10-
quirmg active medical or surgical treatment ,
and when, in the course of vital involution, the
function is being finally obhtoiatcd, it cannot
but be, especially in the complex circumstances
of the artificial life of civilisation, a period of
stress more 01 less severe The sexual life of a
man, although, no doubt, obscurely periodic in
character, has no such definite characteristics
The climacteric is but feebly indicated in the
process of sexual decadence No such active
revolution, intimate in its connection \v ith mind
and body, forces itself upon medical attention.
The familiar facts of the gradual slowing of
life's current in men are ushered in by no such
profound alterations as caused Madame de
Doffand to exclaim, "Autrefois quand j'&ais
femme" For in this relation there is no
question of premature senility, of organic
degenerative nervous changes The woman
who has passed her grand climacteric is in no
way enfeebled, it may bo indeed that her
mental powers are increased and that her
physical eneigies are reinforced since the
menstrual flu\ has ceased to be a recurring
occasion of exhaustive and monthly disturb-
ance. Still, when we consider the neurotic
concomitants of the menopause in women, and
find that these are usually marked by feelings
of a melancholic typo, a conscious loss of
power, irritability, and general malaise, it must
be admitted that similar nervous conditions do
occur m men, although the penod of life is
more advanced, the symptoms are more fortui-
tous, and recovery is less frequent.
We have the high authority of Dr. R. Barnes
in stating that probably few women go through
the reproductive era without some nervous dis-
order They labour under ]>amful, dangerous
tension, often concealing their distress, although
sometimes on the verge of breaking down
What, then, aie the bymptoms of the climac-
teric in women? First, there is a peiiod of
unrest, of flushing, giddiness, tinnitus, head-
aches, and general instability In addition to
subjective signs, there are frequently flood ings,
or other uterine disturbance, which may paws on
to 01 game diseases of the worst type, or may
pass off and leave the person to the enjoyment
of many years of excellent health Too often
those complaints aio treated lightly, as p.irt of
the otdmaiy and inevitable routine of sexual
decadence Too often buffering is endured in
silence and proti acted by unnecessary reticence
But the physician is not warranted in assuming
that these nnnoi tioubles pielinnnaiy to the
cessation of menstruation are of slight import-
ance and undcseivmg of active ticattncnt lie
can never be NIUO that nervous instability \\ill
not piocced to pronounced mental disoider, th.it
flooding^ will not prove symptomatic of cancer-
ous growths Investigation and latmnal treat*
incnt must go hand in hand Piomptitude is
essential
Of lato years the gynaecologist lias been fre-
quently foiced to create an artificial menopause,
and much blame has been deservedly cast upon
those who have been held guilty of carrying
operative measures to extremes They have
been charged, in unseemly terms, with needlessly
unsexing w onion They have been accused of
ci eating greater evils than they removed Cases
have been recorded \\heic the removal of ovaiies
has been detrimental to mental health, and the
last state of the patient tendered worse than
the first An artificial menopause has been fol-
lowed by a climacteric insanity
In the earlier stages of neurotic maladies
associated \wth the climacteric, the bromides
are in common use I have, however, found
general and considerable benefit from the ad-
ministration of ovarian substance in the form of
tabloids There is a disturbance of the animal
economy consequent on excess of natural secre-
tions, but there is also a disturbance depend-
ent upon deprivation If the sudden cessation
of ovarian activity bo accompanied by such
symptoms as have been indicated, it is reason-
able to suppose that the artificial ingestion of
ovarian substance will in measuie restore the
balance which has been destroyed, and gradually
accommodate the system to the new order of
things which is imminent It would seem that
ovarian substance is in those slighter forms of
nervous disturbance, at all events, a valuable
remedy, to be prescribed on reasonable grounds.
CLIMACTERIC INSANITY
159
Within the last few years, especially in
America, few but active workers in asylums
have pressed upon the attention of the medical
profession their conviction of the urgent need
for a more systematic, if not an universal exami-
nation of the reproductive organs of insane
women Operative interference has been ad-
vised in these cases, and one enthusiast has
placed on record that, out of 100 insane women,
pelvic disease existed in 93, and operative inter-
ference was req uned in 89 Such a statement
is altogether exceptional, and has been stmm
ously contioverted Cases have been lecorded
showing that the removal of ovaries has been
followed by disastrous consequences, and that
these operations, generally speaking, have as
little effect in the cure of insanity as the dis-
credited operation of clitoridectomy for epilepsy
Piemature cessation of function, consequent
on disease or consequent on operation, an arti-
ficial climacteric, is assuredly not less hazardous
tnau tho ordinary involution of middle age
It is well known that certain Inxlily diseases
are accompanied by ceitam mental concomitants
JSpei jththwica is familial to every physician, and
the mental depression of liver disease has passed
into a pio\erb The influence of disorders of
tho sexual organs on mental states has been
widely iccogmscd They may determine the
production of hallucinations For instance, it
has been accepted that olfactory hallucinations
are geneially indicative of these disendow, «uid
not less at the menopause Evei since Sclirccder
\an der Kolk insisted on tho icahty of lympn-
tht'ttt inwnitt/ thuic has been no dangei of
ovci looking the condition of the colon in the
treatment of the insane , and perhaps more than
enough has been made of the relations between
the soxual and the mental appaiatus Indeed,
in the active search made foi undcil^mg physical
causes of insanity, the hopes which modern
gynaecological treatment raised have been but
paitially leahsed Tho correction of faulty con-
ditions, however, offcis a cbame of mental
iccovery and must not be neglected
But, it must be admitted, it must be kept in
mind that the great cause of insanity is some
inherited defect Bioadly, the neurotic inherit-
ance is the foundation fact of mental disease
The stress of the climacteric period may tell
soveiely even upon the strongest women When
that stress occurs m the cose of a woman whose
ancestry bears traces of mental weakness, whose
mental instability is part and paicel of her very
nature, the symptoms of earlier and less pressing
importance, such as flushings and giddiness,
should be regarded as indicative of a near pos-
sibility of further deterioration, mental and
physical The physician will seek to obviate
these discomfoits and disorders without loss of
time, so as to prevent the development of moibid
sensations into insane delusions, in so far as he
can, by the regulation of vital functions and by
the details of rational therapeutics and necessary
hygiene He will regard the stress of the climac-
teric as a presumptive exciting cause of mental
disorder in a person constitutionally predisposed
to nervous instability
At such a time a woman may very readily
slip into habits of invalidism The nervous
imtabihty, the physical weakness, the floodmgs
may combine to induce her to adopt a course of
life which is definitely detrimental It may be
that alcoholism, offering a speedy specious lehef,
is an immediate danger, although it is not so
common a pitfall as has been recently alleged
Alcoholic indulgence is not an efflorescence of
late middle life , nor is it reasonable to suppose
that the indecisive, intiospcctive attitude so
ordinarily adopted, intermingled as it is with
religiosity and feelings of un worthiness, can be
a favourable soil for vicious indulgence
The question before the physician is one of
rediess Equilibrium has been deranged The
habit of a generation has suddenly been broken,
the system is not yet accustomed to the change
of current Manifestly h is effbi ts must be towards
the readjustment of equilibiiuin This is not
a meie question of medication or operative mter-
feienco unless these ate demanded by the very
(iicumstances. It is lathci a question of wise
management of daily life, of diet, of exercise, of
repose, of mental occupation and recreation than
invigorating climate To enter on tho punciples
and details involved \\ould mean a needless re-
petition of \v hat \\ ill elsewhere be said in refer-
ence to the ticatment of insanity
INSANITY — It would appear that the ordinary
troubles of the climacteric pass into exaggerated
forms when the boundary line of sanity has
been passed By fine gradations the natural
feelings of advancing yc\us, the weakening vital
impulse, the questionings if work and pleasure
still remain possible, pass into realised feelings
of morbid dtead, of physical incapacity, of un-
uttciable uiiwoithmess The flushings arc ex-
aggciated into beliefs that something has given
way in the head, for continuous headache is
often referred to the veitex or to the occipital
region Feelings of emptiness may alternate
with the belief that some live animal is ci aw ling
about the mterioi of the abdomen The skin
may be the seat of delusions It is common to
find patients complain of being filthy or dis-
eased Tho occurrence of obsessions to wash is
noticeable at this penod of life, as it often is
about tho time of puberty Natuially the
genital oigans participate in these disorders, or
even predominate The belief that pregnancy
has occuricd is very common, although this
condition of p*eudo-cycw is by no means con-
fined to tho climacteric period, nor is it neces-
sarily insane Every practitioner of expenence
will recall cases in which insistence on preg-
nancy at the climacteric has caused consterna-
tion and very real trouble Sensations have
160
CLIMACTERIC INSANITY
been misinterpreted, and the cessation of the |
menses has been held as proof that the false
interpretation of sensations has positive grounds
of truth.
The varieties of insane delusions are numerous,
and are developed out of these morbid feelings
As a rule, they have n sexual foundation For
instance, it is a common phase to complain of
rape having been committed or having been
attempted, especially in the hours of night
Not only may thebo juticnts complain of having
been themselves criminally assaulted, but they
may circumstantially relate that they have been
made aware of fuends or neighbours having
been sitmlaily maltieated This opens up
questions of medico-legal importance, u Inch the
practitioner will do well to bear in mind He
must exercise great caution in his dealings with
persons so afflicted And more especially is
this to be rcmembeied \\hen they fall victims
to epilepsy or epileptoid states, during which
attacks theio may be a peifoimanco of auto-
matic actions requiring the closest observation
in determining the responsibility of the parties
The condition of life as icgards marriage also
determines the toim of the mental mal«uly
The old maid whose life has been narrow, and
whose sympathies may have been warped, will
piobably sufFei from an access of passionate
feeling, the expiring nicker of the candle, and
pester some unfoitunatp man with suggestions
of marital relations, or accuse him of working
upon hei by means of cloctnc batteries, 01
blowing chloroform through the key- hole in
put suit of nefaiious designs On the other
hand, the married woman gives way to nrita-
bihty. or dread, or disappointment, teelmg that
a new relationship has been established between
her husband and herself Instead of passing
from the eailier years of marned life to the
years of a matron's duties, and so to a kindly
green old age, by natural and easy transitions,
the patient becomes exacting and querulous,
expends her energies in a passion of jealousy,
and destroys the home which she had built
up with torn! care These unfortunate first
stops require a world of patience and most con-
siderate treatment They indicate a self-con-
sciousness and a loss of control which, unchecked,
pass to easily recognisable foims of mental aber-
ration
THE CLINICAL FORMS of climacteric insanity
are broadly resolved into melancholia and
mania, with comparatively few cases of delu-
sional insanity of a melancholic type
Melancholia is undoubtedly by far the most
common form The cares of life, the organic
malaise of the climacteric, ordinarily tinge the
mental state with feelings of dread, fears of
impending disasters, fears of impending dis-
abilities The consideration of the clinical
features of melancholia need not be entered
upon here It is sufficient to correlate the
depression and delusions with the underlying
physical conditions
Mama is less common, and would be still less
common were it not that alcoholism plays a
ccitain part in the de\elopment of maniacal
conditions at the climacteric Cases occur in
which melancholia follows on alcoholic excess,
but the usual concomitant is mania Again,
there are cases in which there is a iccuiience
oi mental disordei at the climacteric These
would apjwai to be chiefly maniacal in form.
As to the cases of delusional insanity, where
the predominant features are states of fixed and
limited delusions, these are but few in number,
and the delusions arc almost mvaiiably of a
melancholic i haractei
Still fewer dogeneiate into dementia, and
those are usually complicated by alcoholic or
other toxic influences
Di Savage has drawn attention to the obser-
vation of l)r Tilt that deafness occasionally
occuis at the menopiuse — a defect which may
be temporaiy or permanent No doubt tinnitus
is fiequcntly a symptom of the ehmacteiic, and
it may pass on to inoio serious conditions, but
it does not appear that deafness is in any way
poculiai in its mental complications at th.it
paiticular penod of life It is a matter of
common observation that deaf persons often
become suspicious, morose, delusional, and
dangeious Those afflicted \\ith congenital ot
acquired deafness and insanity are among the
most dangerous of the inmates of asylums They
aie nearly always peiseeutod and perseeutois
In addition to the mental aberrations above
described and grouped according to preponder-
ating symptoms, allusion must be made to ceitain
moral aberrations which come under the notice
of the physician from time to tune Reference
has been made to the alcoholic habit which may
begin with the troubles of the menopause, but
which is moic piolwbly only a shameless exacer-
bation at that penod The excuse comes so
readily that it gi\es the impression of having
been too easily produced, just as the excuse
may have been dysmouorrhcua or puerperal
tioubles in eailici life. It is not usual to find
that a woman of alcoholic habits gives up her
vicious indulgence on the cessation of climacteric
disoiders, on the contrary, it would appear
that she continues to get diunk because she
dislikes being sol>cr The deep-seated untruth-
fulness of the drunkard must l>e discounted in
arriving at any opinion on this question And,
similarly, it is not in accordance with modern
experience to expect that mental disease of long
standing will cease and determine on the com-
pletion of the menopause
Mote serious, if possible, are those cases of
moral insanity in \N Inch nytnphomanm becomes
a prominent symptom Fortunately these are
rare, but when they do occur they are only too
easily recognised.
CLIMACTERIC INSANITY
161
Prognosis.— Having thus examined the general
facts relative to mental disorders occurring at
the climacteric, it is evident that there are no
marked peculiarities other than can be readily
understood on consideration of the underlying
physical and environmental conditions. It will
consequently be gi anted that on the cessation
of tho period of stress there IH expectation that
the recovenes will not bo fewer than m con-
nection with other similar disorders Indeed,
it may bo averred that the chances of recovery
are more than usually favourable, if we exclude
cases complicated by previous attack, organic
cerebral lesions, and the manifestly degenerate
Still recovery may be protracted, though but
tew die The risk of death by suicide is com-
paratively small, notwithstanding the prevalence
of gloomy thoughts and feelings of unworthi-
ness, for the slo\\ er current of life enfeebles the
power to end misery by self-destruction Yet
while this ib generally true, it would be a reck-
less procedure which would fail to take such a
risk into account and fail to take precautions
for prevention
T/ie treatment of climacteric insanity mubt
proceed on the theory of individual necessities
If the sudden cessation of ovarian activity is
causing the mental instability, as has been
aheady indicated, ovarian substance promises
good icsults If tho symptoms are leferable to
the skin, and a harsh dryness indicates slug-
gishness of action, baths and exercise will be
indicated Theie is no class of cases for \\hom
exercise is moie generally beneficial, but ex-
haustion may be so profound that rest and
massage are preferable Or if the alterations in
the appendages of tho skin are the bams of
delusions, these must be treated Removal of
unsightly hair from the face has led to recoveiy
Again, there is often constipation of an intract-
able form, leading to autotoxic effects There
is no better remedy for this than sulphate of
magnesia m small and daily doses These
indications of treatment will servo to show how
closely the physical condition must be studied,
and how treatment must be appropriate to that
condition It may be that the gynaecologist
will be required to operate upon new growths
or to rectify malpositions. In short, if tho
treatment of insanity is to be successful, there
must be no omissions in research and no failure
m performance This is not the place to en-
large upon those measures of mental hygiene
which such patients require, noi is there any
special note of interest in reference to the place
of treatment If appropriate treatment can bo
had without having recourse to asylums, no
doubt that will be tried , but it will be recog-
nised that, for the vast majority of cases of
pronounced climacteric insanity, tho special
appliances and practical experience at the
service of the public in a modern asylum are
both requisite and necessary
VOL. n
Climate and Acclimatisation.
161
161
162
163
. 164
DEFINITION
VARIETIES OF .
GENERAL CHARACTERISTICS
INDIVIDUAL FACTORS IN
CLIMATE AS A THERAPEUTIC AGENT
ACCLIMATISATION
165
flee also DIET (Modifying Factots, Climate),
LIVER, TROPICAL AFFECTIONS (Ifypetoemia, JSffect
o/ a Tiopwal Climate) , LUNG, TUBERCULOSIS OF
(Treatment, Therapeutic, Climate), MENSTRUA-
TION AND ITS DISORDERS (Puberty, Age of),
METEOROLOGY, NEPHRITIS (Etiology, Climate) t
OBESITY (Etiology, Race and Climate), SKIN
DISEASES OF THE TROPICS (Caused by Climatic
Coiutttinni) , THERAPEUTICS, HEALTH RESORTS
(Climate and its Ityett*)
CLIMATE, from tho Greek word K\ivta, I incline.
Lat Chma, Or KAtfia, a region, Fr Chmat,
Glci JSidvtrtth, Jfimmehtnch
Tho \iord climate is now ubed to specify the
definite differences which obtain between one
region and another, as regards temperature and
its variations, humidity and rainfall, the com-
position of tho atmosphere, its density and
pressure, winds, electrical conditions of the
atmosphere, the organic and inorganic sub-
stances it contains, etc The configuration of
the ground must also be taken into account,
the composition of the soil and the presence or
absence of vegetation, marsh-land or desert,
plain or valley, inland or maritime position,
mountainous or otherwise
The term used to be employed in astronomical
or mathematical geography to designate "a
portion or zone of the eatth's surface, comprised
between two lines parallel to the equator, and
measured by tho length of time during which
the sun there appears during the summer
solstice, that is, by the sun's inclination The
space between the equator and the polo was
divided into half -hour climates, m which the
length of each day increased by half an hour,
and also into monthly climates "
As tho climate of a region may be said to be
essentially dependent upon the duration of its
exposure to the sun's rays, modified ceitamly by
local conditions, the relation of the region to
tho equatoi is of great importance Hence,
originally, three great climatic divisions were
described —
1 The hot 01 \varm climate, extending from
the equator to lat 35°, with a mean annual
temperature of about 80° F (27° C )
2 The temperate climate, extending from
the 35th to the 55th degrees of latitude, with
a mean annual temperature of about 60" F.
(16° C)
3 The cold climate, between 55° lat. N and
the poles In this region the temperature varies
from 40° F (5° C ) to 5° F ( - 15° C )
11
162
CLIMATE AND ACCLIMATISATION
A more scientific division of climates is made
by using isothermal lines, because the mean
annual temperature vanes in different regions
occupying the same latitude on the earth's
surface. This would give us five fairly ex-
tensive regions between the equator and either
pole-—
1. The hot region, between the equator and
the isothermic line of 77° F (25° C )
2. The warm region, between the isothermic
lines 77" F (25° C ) and 59" F (15° C )
3. The temperate region, between the iso-
thermic lines 59° F (15° C ) and 41° F (5° C )
4. The cold region, between the isothenmc
lines 41" F. (5° C ) and 23° F ( - 5° 0 )
5. The polar legion, between the isothormic
lines 23° F (-5° C) and 5° F (- 15° C)
Apart from tempoiaturo, lamfall, winds, etc ,
to which icierence will be made presently, for
practical purposes we must refer to seven
climates r—
1 Hot climate
2 Temperate climate
3 Cold climate
4 Insulai climate
5. Maritime climate.
6 Continental climate
7 Mountainous climate
As all those climates have general differences,
it will be well to briefly describe them befoio
referring to details
(iKNKiuL CHARACTERISTICS — 1 The hot climate,
which may be described as practically extending
to 35° north and south of the oquatoi, contains
within its limits South Asia, nearly all the
islands of Polynesia, the greater pail of Africa
and its islands, and those parts of North and
South America lying between the latitudes
mentioned
In these regions the heat is greatest, not, as
might be imagined, at tho equator, but at the
tropics (20°-23° 30") The heat at the equator
is modified by the equatorial rains, which fall
almost daily, and the equatorial calms, but
although the rainfall is fairly equally distributed
during the whole year it only amounts to about
45 inches in this equatorial region Between
5° and 10° of latitude there are two rainy
seasons in the year In regions between 10°
and 13° there is one lamy season, which lasts
upon an average for five months These general
considerations are modified by the monsoons
The variation in tho thermometer is slight
during the day, but at night there is often a
considerable fall In general terms, tho range
of temperature is from about 55° to 120° F
(13° to 49° C ) The daily vaiiation in baro-
metrical pressure is well marked, but the general
variation is slight
There is an almost rainless area north and
south of the equator from about 16° to 28°,
where it seldom or never rams, and in these
belts the moan annual temperature is greatest
Throughout the hot climates thunderstorms are
of frequent occurrence
The general influence of the hot climate upon
the inhabitants is to render them lazy and
apathetic It has a very definite influence upon
the constitution of Europeans residing there,
and the physiological functions of the body are
distinctly affected With regard to the normal
temperature of the body, we find that, according
to numerous observers, it is slightly raised,
probably about 0° 40 F (0° 04 C ), but the
mean diurnal ditterence of temperature is
practically tho same in Europeans as seen in
Europe Crombic found that the moan tempera-
ture of Europeans in Bengal, taken in the
mouth, uas 98° 49, with a maximum daily
range of 1° 31, as compaicd with the English
average of 98° 084 and 1° 41 respectively With
regard to teipiiation, Rat ti ay's observations arc
summarised by Davidson thus " Tho vascularity
ot tho adult lungs is reduced by 12 to 13 fl oz ,
their spno metric measuiemcnt by the aveiage
of 32 inches, their function by 18 43 per cent,
that is, they use 3685 cubic feet less of an
daily , the excretion by 1 84 oz loss of carbon
and 6 7 less of watery vapour " This is accounted
for by the number of respirations being lessoned
to about 14 per minute, and there being con-
siderably less blood in the lungs under the
influence of an aveiage ternpeiatuie of from 80"
to 83° F (27°-285'C)
There is a very slight difference m the jiiUw
rate, and tho proportion between the respirations
and the pulse rate is not tho same as in Europe
Tho amount ot mine voided is diminished in
quantity llattray says that it is diminished
by 17^ per cent, but, of course, the amount ol
urmo depends upon the amount of fluid con-
sumed, the temperature, and the humidity of
the atmosphere
Opinions vary as to the effect of a hot climate
upon the blood, and for this reason that prob-
ably malaria must be taken into consideration
On tho whole, however, it is safe to say that
Europeans suffer from a slight ano?mia By
some authors tins is considered physiological
anosmia, and rather beneficial than otheiwise
The netvou* system during the first few
months of a residence in a hot climate is
excited, but this excitement soon gives rise to
depression, which latter is partly due to loss of
sleep, partly to climate, and also to the worries
incidental to a residence in a hot climate
Dicjertion is slower than it is in Europe, and
digestive poweis are weakened, tho appetite
fails, and nutrition is diminished, weight is
lost, and the muscular system enfeebled The
functions of the liver and skin are greatly
stimulated Menstruation commences about
one or two years sooner than in Europe
European children born m hot climates thrive
fairly well in infancy, apart from their liability
to suffer from diseases incidental to the climate.
CLIMATE AND ACCLIMATISATION
163
The mortality m the hot climates in new
arrivals is chiefly due to fever, heat apoplexy,
and intestinal disease, but after a year or two's
residence these diseases show a marked diminu-
tion in amount It must also be admitted that
sanitary measures and a more careful mode of
living have greatly reduced the amount both
of disease and moitality in Europeans m hot
climates, thus the death-rate from disease m
India among soldiers, excluding cholera, has
decreased by two-thirds since the 'sixties, \vheu
the British soldier m Bengal died at the into of
some 60 per thousand The death-rate of
soldiers in Bengal in 1888, excluding cholera,
was 10 54 per thousand The inoitahty ot the
women, however, WAS somewhat higher, The
death-rate of soldiers' children undoi one vcar
was 189 64 in 1888, but it miibt be remembered
that in India they do not suffer from the want,
piivation, and exposure to which children aio
subjected in the largo towns of England, wheie
the death-rate is very little lower, and in older
to estimate these hguies aught we must also
rcmembei that, as Davidson points out, "the
diminished moitality is the result of withdraw-
ing soldiers' children fiom the tropical influences,
which piovcd HO mj in ions, and tearing them m
atempeiate climate", this is done by taking
the childien from the plains to establishments
in the hills in the hot season
2 Tfte Template Chnmte - -This climate is
the healthiest upon our globe, as ueithci the
cxti ernes of heat nor cold aie experienced It
may be said to l>c situated between latitudes
35° and 55' The mean aumml temperature
varies from 50° to 60° F (10°-16° C) In
the tcmpeiatc regions we ha\e the four seasons
— spnng, summer, autumn, and >vmtei, — and
thcie arc probably gi cater differences in local
climates than elsewhere It is in this area,
too, that the influence of largo towns and
country districts must be taken into account, for,
undoubtedly, the overcrowding which obtains in
gieat cities docs not tend cither to longevity or
to lobust health, whilst infant moitality is \eiy
high Great differences, however, obtain in
different places, owing to the advance which
sanitation has made If we compare the death-
rates of the vaiious capitals oi Euiope we find
marked differences , foi instance, the death-rate
in London is one-thud less than in 23t Peters-
burg or Moscow Certainly the healthiest
climates m the woild are to be found m this
temperate zone, and wo possess far more
accurate knowledge with regard to the diseases
of this area than of any other As will be seen
in the article on "Health Resorts," they are
practically all to be found m temperate regions
3 TJie Cold Climate-— This climate, which
covers the areas from about 55° F. (13° C ) to
the pole, has been divided by some observers
into three — the cold, having a mean animal
temperature of from 40° to 50° F (5°-10° C ),
the very cold, a mean annual temperature of
32° to 40° F (0°-5° C.), and the glacial, where
the mercury is below freezing -point In the
northern hemisphere, northern Russia, Lapland,
Finland, Iceland, Norway, Sweden, Denmark,
the north of Scotland, Spitzbergen and Nova
Zembla, Canada, northern Asia, Siberia, and
Kamtschatka, as well as Gioenland, ho within it
Although cold severely tries the lungs and
kidneys, yet, accoidmg to M Levy, the death-
rate in this region is the lowest m the world
His estimate with regard to it may here be
quoted —
From 0°-20° latitude, 1 death takes place in
25 inhabitants , fiom 20°-40°, 1 in 35 5 , from
40°-60Q, 1 m 43 2 , from G0'-80°, 1 m 55
The inhabitants of this region are vigorous
and musculai, then powers of digestion are
remarkable, but their ueivous systems are not
highly developed
4 The Inwlar Chninte — This climate is
remarkable in many ways, the seasons are
more equable, owing to the Htinoundmg water.
The air is constantly changed by the pre\alence
of winds, and is charged with abundance of
moisture
5 T/te Maritime Climate — This much re-
sembles the insular climate It is wainier in
winter and cooler in summer than the conti-
nental climate, for, as a rule, the lange of
tempeiiiture increases fiom the coast towards
the intenoi The annual range of tempciature
on the coasts of the great oceans is diminished
to about 20° F ( - 7° C ), whereas in the interior
of a largo continent, as, for instance, in the
centre and north of Asia, the rango may be
fiom 60° to 100° F (16e-38° C )
6 T/ie Continental Climate — This climate
has a tendency to extremes of temperature —
cold winters, hot summers, — and even at a
shoit distance from the sea these changes
obtain
7 TJie J/oMHfrutt.otf<t Climate — Heie we have
a low barometric piessure due to altitude, the
air being more and moic raiehed as we ascend
The heat diminishes, but the mountains attiact
clouds and wateiy vapour, this notwithstand-
ing, the climate is unusually healthy The
air is exceptionally puic On first going to
high altitudes, the respnations and puke are
accelerated, and the amount of carbonic acid
and water exhaled by the lungs is mci eased,
but after a residence of from one to foui weeks,
the pulse falls to normal, the respiration, how-
ever, continuing fuller than it was on the plains
A consideration of the ocean climate will fall
more naturally under the heading of " Health
Resorts," but it may be said to bo essentially
characterised by warmth, equability, and ex-
cessive moisture
INDIVIDUAL FACTORS — Considering now more
in detail, but yet briefly, the various factors
which are summed up in the comprehensive
164
CLIMATE AND ACCLIMATISATION
term of climate, we turn first to the composition
of the air. Roughly speaking, m 100 volumes of
air, we find there aie of oxygen 20 96, nitrogen
7900, carbonic acid 004 The amount of
oxygen in the air varies to a considerable ex-
tent, but rarely exceeds one-tenth m volume ,
the carbonic acid in the atmosphere vanes
considerably also ; it may bo in the proportion
of from 4 to 30 in 10,000 , there are also m the
atmosphere other substances of a gaseous nature
— ammonia, ozone, etc, as well as solid sub-
stances floating in the an, which vary m
different places and under various conditions
Obviously in large towns one would expect
these adventitious particles to be far more
abundant than in the country The suspended
matters m the atmosphere are of considerable
importance, and indeed it is upon the recognition
of these that Lister's antiseptic theory has been
based
The tcmperatwe of the air naturally albo
influences climate, and m this connection we
have to distinguish between the sun heat or
radiant heat, and the air heat or shade tempera-
ture, which is due to the waimth imparted to
the air from the ground, unless influenced by
wind. " The nature of the surface of the ground
exercises gieat influence on the amount of heat
which is absorbed and reflected , the nearer the
colour of the ground approaches to white (snow,
chalk cliffs, white walls, etc ), the more direct
the sun heat reflected by it, the less heat being
absorbed , the darker the gzound (grass, green
leaves), the less heat reflected and the more
absorbed. The ground which absorbs more heat
from the direct rays of the sun can give out
more hoat during the night, and vice veina
The influence thus exercised on the climate of
a place is evident, and the white snow-fields of
the Alps m wintei form a well-known illus-
tration "
The temperature of maritime regions is
influenced by the ocean, and m mountainous
regions altitude lowers the moan animal range
of temperature
With regal d tt> txuvmetoic pressure, it must
be noticed that, if great, it exerts a very maikcd
influence upon the human being It tends to
mcicase the amount of caibonic acid and water
exhaled by the lungs, and at first to induce
laboured respiration and inability for exercise,
as well as constipation and depression
The influence <if light is also important, and,
owing to its action on the centripetal ncivos, it
increases the metabolism
Winds purify the air and induce changes in
temperature, atmospheric pressure, moisture,
and light, and therefore they must be taken
into consideiation, not only with regard to
climate m general, but as to health resorts m
particular The mousoon winds, the sirocco,
and the kamsm are beneficial or untoward
factors where they obtain.
The cultivation of the soil exerts an influence
upon the temperature, for cultivated land, which
is well drained, raises the temperature, as has
been demonstrated by Buchan It is obvious
also that vegetation must play a marked part,
because where it is luxuriant the sun's rays
upon the ground arc moio or less prevented.
(J round covered by forests has a lower tempera-
tmo than that which is bare, and the diurnal
vaiiatiou in well-wooded districts is more equable
than that in open country It is obvious also
that sandy, diy, and well-drained soils are much
waimcr than wet and marshy districts, which
certainly produce mist and fog A sandy desert
is exceptionally warm in summer, although com-
paratively cold m wintei
The amount of watety vapour m the atmo-
sphere is also an important factor of climate
Evaporation and condensation constantly alter
the humidity of the atmosphere As a rule,
absolute humidity is gicatest with a high tem-
perature, but relative humidity is usually greater
m winter than in summer It is only when
saturation of the air obtains that we have mists
and clouds, — clouds picdominating at average
heights, mists clinging to plains and maritime
positions, or the neighbourhoods of large lakes.
On mountain tops mists are rare
With regard to rainfall, its distribution is
unequal over the globe and vanes in amount,
from 300 to 400 inches annually on the southern
slopes of the Himalayas, to almost nothing in
the Sahara Again, the number of rainy days
experienced annually varies greatly, and does not
invariably correspond to the amount of ram
which falls Rainfall is not always injurious,
as it diminishes the amount of impurity m the
atmosphere , but, in considering the climate of
a health resort, the amount of rain, the rainy
season, the number of days ou which ram
falls, and the time of tho day, aro all subjects
foi consideration, as far as invalids are con-
coined
It should be remembered that where moun-
tainous regions he in the path of moist air cur-
rents rainfall is great, as, for instance, the Khasi
range of hills, which have an annual rainfall of
about 500 or 600 inches, for they intercept tho
S W monsoon, which, laden with vapour from
the Bay of Bengal, impinges on them On the
lee side of mountains, however, the rainfall is
less
Although the electrical condition of the atmo-
sphere must play some part m climatology, its.
practical importance is insufficiently understood
Climate must also be considered with refer-
ence to the treatment of disease A change of
climate cannot be said to be a specific m ti eating
disease, but there is no doubt that in many dis-
eases a change of climate acts most efficaciously.
It is a well-known fact that the removal of a
patient for even twenty or thirty miles may be
exceedingly beneficial In choosing a change of
CLIMATE AND ACCLIMATISATION
165
climate for an individual, the patient's personal
equation or idiosyncrasy must bo taken into
account In dealing with patients suffering
from nervous diseases, in whom we wish to
restore the general tone of the system, we
should choose bracing and moderately temperate
climates, remembering that proximity to the sea
may induce nervous excitement and insomnia,
and may, temporarily at least, exaggerate neur-
algias Diseases of the lungs, apart from
phthisis, are favourably influenced by a climate
characterised by moisture and mildness A
bracing equable climate is requisite in cardiac
disorders, remembering that pulmonary com-
plications due to climate should be avoided A
moderate altitude is usually beneficial, but the
patient must not be sent too rapidly to a high
altitude, and very sudden changes of tempeia-
ture must be avoided In diseases of the ab-
dominal organs, such as intestinal catarrh,
chronic liver disease, dyspepsia, dysentery, dia
betes, etc , change of climate may be most bene-
ficial, climates such as the Riviera, the Nile,
St Montz, and Morocco being advisable This
will be further considered under "Thciapcutics,
Health Resorts "
AccuMAiiNA'iiox — The question of acclima-
tisation naturally falls under the subject of
climate Tn recent years two schools of thought
have Ix^en formed — one icgarding acclimatisa-
tion as impossible, a view supported by Virchow,
Ilir&ch, Fritseh, llavenstcm, and others, who
hold that Emopeans can nevci become acclima-
tised in the full sense ot the word in tropical
regions, believing that the deterioration caused
by Himatological fat-tors and endemic diseases
will invariably kill off the emigi.mts, or at any
rate render their ultimate existence impossible ,
the other school, represented by Do Quatrefages,
Livingstone, the Lite Bishop Hanmngton, and
more recently by Dr L Sambon, believing that
rapid acclimatisation in tropical regions is pos-
sible for Euiopcans The wnter of this article
holds that rapid acclimatisation in tropical
regions is impossible, and that acclimatisation
for Europeans can only bo possible if migration
occur step by step In estimating the pos-
sibilities of acclimatisation we must count by
generations rather than by years, although,
given carefully selected individuals and care-
fully selected tropical areas in which to colonise,
he sees no reason why, with precautions, Euro-
peans should not colonise even m the tropics In
making the selection, all persons with a tendency
to gout or rheumatism, diabetes or albummuria,
those with a nervous or alcoholic family history,
or those suffoung either from acquired or heredi-
tary syphilis should certainly bo rejected
Acclimatisation is a process, usually slow, by
which plants and animals become adapted to,
and so retain health m, countries having a differ-
ent climate from those in which they are indi-
genous , it is m part effected by changes taking
place in the individual or in the race, in part
by heieditary modification of constitution If
\\e look at the distribution of different races
throughout the world, we find that great changes
have taken place m their location , the Esqui-
maux once lived in Asia, only some 40° north
of the equator, now they inhabit the polar
legions , the Bohemians or Gipsies are found
nearly everywhere, while Jews and Maltese
apparently thrive in every conceivable legion
But, examining the matter more closely, we
find that the Esquimaux did riot arrive at their
present hunting-grounds in a generation, much
less in a few weeks, as emigrants and soldiers
are compelled to do now, nor do wo find that
the Gipsies or Jews overspread the world rapidly.
Feu from it, they put out feelers, as it were,
and only very giadually, year after year, genera-
tion after geneiation, did they advance from
then native soil into the great unknown Look-
ing for a moment at other races, we obscive that
the British become acclimatised at the Cape, in
Southern Australia, in New Zealand, and in
some parts of North America, but not in India
The French thrive in Nova Scotia and in Maur-
itius, but not so well in the north of Algeria,
although in the southern provinces they do
better The Dutch fare exceedingly well at the
Cape, but not in the Malay Peninsula, whore
they ha\e experienced fearful mortality Mada-
gascar may bo instanced as a place having a
climate which has proved most unfavourable to
all Europeans
In dealing with the subject of acclimatisation
with refeience to Kuiopcans, an erior is made
in imagining that all Europeans ran be acclima-
tised or will resist acclimatisation in any given
aiea equally , not so, a marked difference obtains
between noithern and southern Europeans in
this respect Not only the climatology of their
original residence must be taken into account,
but also their habits and customs and their
psychical peculiarities, and if these factors have
to l>e consideied with regard to the adaptability
of a nation for emigration, so too with regard to
the individuals of any nation Selected in-
dividuals fiom nearly every European nation
may thuve almost all over the world Some
have denied that emironment influences the
human species, and it has been said that nations
seek out that environment which is best suited
for them , but environment certainly does defi-
nitely influence not only individuals but nations
Heibert Spencer has shown in his J'nnci/t/es of
Biology that every oigau and every function of
living beings undergoes a certain and definite
modification, within certain limits, under the
stimulus of new conditions', and he thinks that
this modification is almost always such as to
produce an adaptation to a now environment
The influence which climate and environment
exert upon emigrants is well shown m Australia,
New Zealand, and America, proving that a race
166
CLIMATE AND ACCLIMATISATION
such as the Anglo-Saxon may undergo material
changes. It is obvious that the Colonials of the
present day are practically different from thoir
ancestors, and they indicate a tendency to
change to an altogether new type of manhood,
with new aptitudes and capabilities
Broadly speaking, Europeans can only become
rapidly and readily acclimatised m the temperate
zone, that is to say, where climatic and other
conditions are approximately akin to their present
habitat It may also be said that people who
inhabit the temperate zone become more easily
acclimatised m countries towards the north of
their present habitation
It is interesting to notice that the peoples
of Southern Europe, such as the Italians and
southern Frenchmen, can better bear the climate
of sub -tropical Africa than can Northern
Europeans, and, as Mr Ravenstem has pointed
out, " a steady stream of migration is, in fact,
setting in that direction. Germans and Belgians
are pouring into Franco, Frenchmen are going
to Algeria, the Arabs from the shores of the
Mediterranean have found their way into the
Sudan, whilst the Sudanese are pushing forward
into Bantu Afnca. The descendants of those
Dutchmen who, a couple of hundred years ago,
first settled at the Cape, have made their way
to the Transvaal, and European migration,
favoured by geographical features, is being
pushed, oven within the Tropics, towards the
Zambesi "
In treating the subject of acclimatisation,
some have simply divided mankind into two
classes, white and black, but tins is a far too
sweeping generalisation, and it must be examined
more closely if a definite and right conclusion is
to bo arrived at An endeavour must be made
to prove with certainty m each separate case
what power of resistance is possessed by any
given national constitution, in order to decide
whether it may successfully acclimatise itself in
a new country and permanently colonise In
white races there is apparently a marked grada-
tion m their susceptibility to climatic influences,
and a very decided difference is noticed betaeni
the Aryan and Semitic races in this respect
The Arabs and the Jews are both unequalled in
their power of adapting themselves to new en-
vironment, but even between them a difference
exists, in so far as the Je\\s appear to continue
definitely capable of reproduction, although they
marry amongst themselves, while the Arabs
often Hiitfcr from degeneration which is only
retarded by the introduction of now blood
They take wives from the races among whom
they settle and thereby continue to exist, but
this is not true acclimatisation, for the race is
altered and transformed into a mixed race, which
eventually possesses very little in common with
the original stock Race itself does not always
provide us with a definite clue to capability of
acclimatisation, for in India the Hindu popula-
tion, notwithstanding its Aryan origin, has
thriven under unfavourable circumstances and
even in malarial districts, presenting a striking
contrast to the English (also an Aryan race),
whose intoleianceof the Indian climate is obvious
Temperament also plays a not unimportant part
in the possibility of prolonged existence in a
given region It is a quality which requires
considerable tune to bo modified by new condi-
tions of life, e g the Indian at Brazil is dull and
sullen, the negro is vivacious and gay, although
m the same climate Hereditary temperament
and capacity of mind characterise variously all
races, and differences of intellectual and moral
power are well-marked factois m the possibility
of acclimatisation Virchow not long ago pointed
out, with reference to acclimatisation, that two
distinct questions are usually confused, viz (1)
How long can any single individual, with pre-
cautions and care, live in any particular climate ?
(2) what laces can thrive and colonise in any
particular climate? No definite answers arc
yet possible In answer to the first it may,
however, be said that selected individuals may
live for a time anywhere with piecautions With
regard to the second, rapid acclimatisation of a
race can only be obtained if it migiates to regions
having approximately the same climatic condi-
tions as its original habitat If Europeans, for
instance, attempt to colonise in the tropics, they
almost invariably die out In the West Indies we
have a striking exemplification ot this, and even
in Cuba, which is brought forward by some
authorities as a proof to the contrary, the
apparent increase in the white population is
more than accounted for by immigration Tho
permanent decrease of the white population m
the West Indies dates from the abolition of
slavery , as overseers and occupieis of the soil,
Europeans arc able to withstand climate moie
successfully than when they are compelled to
undertake actual manual labour The white
man's incapacity for manual labour is an im-
portant question throughout the tropics , it has
necessitated the employment of Chinese labour
in Ameiica, of coolies in Mauritius and Java,
and of kidnapped natives from tho South Sea
Islands in Australia
From what has been said it is obvious that
Europeans are almost incapable of colonising in
the tropics — almost, because there arc some
places in the tropics occupying a high altitude,
and some islands whose climate is so modified
by the surrounding water and by their exposure
to winds, that they almost possess a temperate
climate For instance, in tho Vmdhya hills m
India the French have colonised successfully,
and, theoretically, there is no reason why
Euiopeans should not colonise and thrive m
some of the highlands of Central Africa, when
railway communication has been provided to
carry them rapidly across tho dangerous belt of
malaria on the coast
CLIMATE AND ACCLIMATISATION
167
If we desire an example of a race thnvmg in
extreme vicissitudes of climate, it is to be found
in the Indians, who, coming from a temperate
region m North America, have become ac-
climatised in the hot dry coasts of Peru, and
also in the extremely cold regions of the Andes
at an altitude of 4000 to 6000 feet Now, not-
withstanding that the inhabitants of these two
regions will not thrive if they are removed from
one to the other, they have nevertheless proved
the possibility of an original race becoming
gradually acclimatised m aioas which are totally
different from a climatological point of view
Bcrtillon well summed up the circumstances
% hich go far to prevent sudden acclimatisation
m new ibothcrmal regions —
1 Acute diseases, many of them endemic
2 Chrome consecutive anaemias, which place
the individual in an unfavourable position to
resist accidental disease
3 Diseases in early infancy in offspring in
the new home
4. Physical and intellectual degeneration and
the infertility of the second and thud generations
That climate markedly affects the progeny of
emigrants is certain , for instance, when Europeans
proceed to countiies where they can colonise,
which possess a very different climate from their
own, their chilrhen in a generation or two re-
ceive an indubitable impress fiom the climato-
logical Victors around them The children of
Europeans \\ho go to North America tend to
approach in type to the original inhabitants of
the soil, they outwardly resemble the north-
west American Indians, tho hair becomes
straighter, coaiser, daiker, the cheek bones
more prominent, and the rounded ioim of the
face changes into the gaunt-lined face typical of
the inhabitants of the United States , the skin
becomes somewhat sallow, and oven the voice
changes Again, supposing a woman proceeds
to Australia, having given birth to three or four
children , the children she subsequently bears m
the new climate will not resemble her previous
In tropical countries we find that the children
of noi them European families do not thrive,
and the race dies out, not so much because of
tho infertility of the women, but because of
their inability to beat children capable of thriv-
ing In those cases \vheic the women are sterile
it is due to the action of the climate upon them
as Europeans, and not to any specific action on
the sex
.— The study of climates
and of the effect they produce on the health of
the individual or of communities See CLIMATE
Cllffllatrla. — Clinical medicine , is derived
from xXtinj, a bed, and tarpcia, treatment
CllniC Or Cllnlqiie.— A gathering
of medical students or post-graduates in a
hospital for the purpose of acquiring a know-
ledge of clinical (or bedside) medicine or surgery ,
sometimes the name is given to the patients
(clinical material) gathered together for teach-
ing purposes, or even to the building in which
tho instruction is given.
Clinical.— Relating jo practical or bedside
treatment or instruction in medicine or surgery,
as opposed to theoretical lectures and demonstra-
tions, eg Clinical Medicine, Clinical Surgery,
Clinical Gynaecology, etc See ABDOMEN, CLINICAL
INVESTIGATION, CHILDREN, CLINICAL EXAMINA-
TION OF , G\N^COLOGY, DIAGNOSIS IN , etc
CllnOCOphaly.— A malformation of the
head in which it is flattened on tho top, saddlo-
frhaped , it is due to synostosis of the panctals
with the sphcnoidal great itingH or with the
bquamous temporals
Cl I nodacty I ism. — The malformation
of the foot or hand in uhich one digit overrides
another
ClinOSCOpe.— An instrument for detect-
ing and measuring deviation or declination m
ophthalmology
Clitoris. — The erectile organ situated at
tho apex of the \estibulc in the anterior region
of the vulva See GENERATION, FKMALE ORGANS
OF (Extenwl) It has been icmoved (chtatir
dectomy), but "\\ith vuiy doubtful benefit, in
cases of nyinphonmnia tfce also LABOUR, POBT-
PARIUM HJKMORRIIAI.E (Primary, Traumatic),
SYPHILIS (Ptimary), TABKS DOHSALIS (Nympto-
matoloyy, Genttnl Organs), UTERUS, MALFORMA-
TIONS OF (1/ypettoojphy of Clitoris), VULVA,
DISEASES OF HIE (TWowa, Mm bid Conditions
ofClttotii)
Cloaca* — The space or opening into \vhich
the intestinal and uimo-gemtal canals discharge ,
a cloaca exists normally during embryonic life
m the human subject, and it may remain per-
manently as a malformation («e% GENERATION,
FKMALE ORGANS o*, Jfaffonnahani), or be pro-
duced trauinatically during a prolonged or
instrumental labour (PELVIS, PERINEUM AND
PEIAIC FLOOR, Lesions) , the name ilwtra is also
given (m suigery) to cavities containing pus, or to
holes m the m\olucrum of new bone in diseases
of bones, e g in acute osteomyelitis and pciiostitis
(we BONE, DISEASES OF)
ClonlC. — Clonir (from Gr KAOVOS, irregular
motion), as applied to movements, signifies
irregularly occurring contractions alternating
with relaxations, e g in epilepsy, eclampsia, and
hysteria , it is opposed in meaning to tonic
Clonus. — A series of contractions of tho
muscles of a limb or part of the body, causing
rhythmical jerks or movements, e g ankle clonus,
168
CLONUS
wrist clonus, knee clonus (patellar reflex), pro-
duced in normal or abnormal amount by tapping
or sharply stretching one of the tendons. See
TBNDON-JKRKH.
ClOquet'S Hernia. See HERNIA,
FEMORAL (Pectineal Hernia)
ClOSOt. See SBWAISE AND DRAINAGE
Clothing1. See DISINFECTION (Pi optical) ,
NURSERY HYGIENE (Clothing), PREGNANCY,
MANAGEMENT (Clothing)
ClOUClS. See METEOROTXDGY (Fog and Mist)
Cloudy Swelling1. — Swelling with
turbidity (in excess of the normal) of the proto-
plasm of the cellular elements of a tissue, due
to interference of some sort with the life of the
cell or its metabolism , the turbidity is due to
the presence of granules in the cytoplasm, and
the granules are either extraneous substances
taken into the cell or precipitated mattcis which
are normally present bat in solution , the swell-
ing is caused by imbibition of water, fatty
degeneration may occur as a subsequent change
or the cells may return to the normal, the
organs whose cellular constituents are thus
affected (kidneys, Iner, heart) arc larger in size,
paler in colour, and of a softci consistence than
normal. Among the common causes of cloudy
swelling are tonnes (eg of fevers), heat, and
certain organic and inorganic poisons (e g abrin,
corrosive sublimate)
ClOVe-Hltch. — A catch 01 noose for
temporarily fastening things together or for
making traction on a part , in surgery a bandage
or towel may be used for this purpose, the
bandage so used is passed twice round the limb
in such a way that both ends pass under the
centre part of the loop in front, thus —
Cloves. See CARYOPHYLLUM
ClOWn Ism. — The stage in a hystero-
epileptic fit during which curious contortions
occur along with maikod signs of emotion , it
is preceded by epileptic or epileptoid convul-
sions, and is usually followed by the assumption
of an attitude expressing fear or ecstasy
Club -Foot. See DEFORMITIES (Lower
Extremity, Foot) , ANKLE-JOINT, REGION OF,
DISEASES (Tabettc Arthrojxxthy) , BURSJS, INJURIES
AND DISEASES (tfimjft Chronic But situ) , HYDRO-
CEFHALUS (Complications]
See DEFORMITIES (Hand,
Club-Hand.
Club-Hand).
Clubbing of Fingers and Tc
See BRONCHI, BRONCHIECTASIS (Clinical Phe-
nomena), LUNG, TUBERCULOSIS (Complications,
Integumentary)
Clupea Thryssa.— A poisonous fish,
the sardine dore of the West Indies See SNAKE-
BITES AND POISONOUS FISHES
Clyster. —A clyster (Or *Av£«i/, to wash
out) is an enema or injection, used for the pur-
pose of administering nutriment per rectum, or
for procuimg an evacuation of the bowels, the
name is also applied to the pipe, syringe, or
tube which is used
Cnemlal.— Relating to the leg or tibia,
from Ur *w;f»?, the leg, thus cnemelep/tantiam*
is elephantiasis affecting the log, cnemttis is
inflammation of the tibia, cnemolordosis is for-
ward curving of tho leg, and cnemo*io?iosn is
lateral curving of the log
CneslS. — Itching The word is derived
from Or KVO.W, 1 scrape or sciatch, and Kvijo-fj.at
an itching, thus cnevnwpomphdyjc is itching
pemphigus, and methocampa tho name of a
species of catci pillar which causes urticaria
epidemica in some parts of Swit/erland
CnldOSiS. — Urtication or the sensation of
being stung by a nettle (Gi KviSrj, a nettle) ,
the skin disease, urticaria
Coagulation. — The conversion of a fluid
(the blood) into a bolid jelly, followed in a short
time by the separation of the clot fiom the
serum See BLOOD (Plasma and Set urn, Nature
of Coagulation) , PIIYSIOLCXA, THE BLOOD (Clot-
ting or Coagulation)
Coagulation-Necrosis.— A second-
aiy post-necrotic change in the tissues, charac-
terised by spelling and transformation into
"homogeneous masses of an increased consist-
ence," as seen in mfarcts of the kidney and in
other tissues in toxic states
CoagU 1 1 ns. See BLOOD, TEST FOR HUMAN ,
PRECIPITINH
— The gas obtained by the
destructive distillation of coal, consisting of
defines (ethylene, G2H4, methane, OIL, etc),
hydrogen, carbon monoxide, carbon dioxide,
nitrogen, and sulphur compounds (the three
last-named constituents being impurities) See
VENTILATION AND WARMING Water gas, which
is produced by the action of superheated steam
on red-hot fuel, consists of carbon monoxide and
hydrogen, with hydrocarbons or illummants
added to it (carburetted) , it is poisonous and
ought therefore to be " odonsed," for it has no
169
smell. See TOXICOLOGY (Gaseous Poisons,
Carbon Monoxide).
Coal-Miner's Dermatitis. See
DERMATITIS IN COAL-MINERS
Coal-Miner's Lunff. See ANTHIU-
cosis , LUNGS, PNEUMONOKONIOHIS
Coallne. — An alkaloid obtained from
decomposing meat See INTESIIMSH, DISEASES
OP (Enteritis, Exciting Causes)
Coaptatlon.— The careful and exact
approximation of two separated parts (the ends
of the bones .it a fracture) to each other
Coarctatlon. — The constriction or
diminution in size or calibre of a part, eg A
blood-vessel or the intestinal canal
Coat* — A layer of tissue, u membrane, or
covering (e y muscular and mucous coats)
See alfo BUFFY COAT
Cobalt- — A metallic element (Co), occur-
ring in nature as the aisemde (CoAs2), or as the
arsenide and sulphide (CoAsS, or cobalt-glance) ,
solutions of cobalt chloride form a symjxithehr
vnk , the salts of cobalt are poisonous and kill
by arresting the heart's action , primary cancer
of the lung is remarkably common in the cobalt
miners of Schneeberg
Cobras, foe SNAKE -BITES (Elapidcv,
Naja)
Coca. —Coca or Cuca consists of the dried
leaves (Cone Folia) of Kt i/thi oxylon Coca, it
contains the alkaloids cocaine (mcthylbenzoyl-
ccgonme), cocamme (is.itrophyl-coc<unc), and
cinnamyl-cocame , it has an official prepaiation,
the Ext tat turn Coco1 Liquidum, given in doses
of £ to 1 fl dr , and its action is due to the
cocaine contained m it See COCAINE
Cocaina. See also COCA, COCAINE —
Cocaina is insoluble in water, but soluble in
alcohol, ether, chlorofoim, and olive oil Pre-
paration— Unguentum Cocamw, strength 4 per
cent Cocainai Jfydrochforidvm is a crystalline
powder, freely soluble in water, alcohol, and
glycerine Do*e — \-% gr Preparations — 1
Injectio Cocaina) Hypodermica, strength 10 per
cent. Dose — 2-5 m subcutaneously. 2
Lamellro Cocameo, each containing -fy gr 3
Trochiscus Kramerue et Cocamee, each con-
taining -fa gr
The liquid extract of coca has been
administered as a sedative and bitter in
irritable stomach. Cocaine is used largely as a
local anaesthetic, although within recent years it
has been superseded for many purposes by other
drugs having a similar local action and less
general depressant effect. For aueosthesia by
lumbar injection it has almost entirely been
given up in favour of other substances, such as
stovame and novocam The lozenges of
kramena and cocaine are useful in sore throats.
A 10 per cent solution is painted on the throat,
if necessary, before making a laryngoscopic
examination , and weaker solutions in the form
of a spray are employed in painful laryngcal
phthisis to enable the patient 'to swallow tood
In operations on the nose, throat, or any mucous
surface a solution painted on gnos complete
local anaesthesia For operations on skin sui-
iaces it must be injected with a syringe, and foi
this purpose a 2 per cent solution with the
addition of a little adrenalin chloride is recom-
mended A drop or two of a 5 per cent solu-
tion placed on the conjunctiva causes dilation of
the pupil and is helpful m ophthalmoscopic
examinations Solutions varying m strength
fiom 2 to 10 per cent are employed for local
anaesthesia m eye opeiations Cocaine ha*» been
given by the mouth m inflammation of the
ousophagus, m cancer ot the stomach, in
gastralgia, and in sea-sickness The ointment
is valuable in painful fissures, ulcers, etc , and
in pruritis Suppositories and bougies con-
taining cocaine arc occasionally employed
Cocaine.
PHYSIOLOGIC M. Aciiov 170
METHODS o» APPLICATION 170
USES 170
DANGERS 171
EUCAIXE 171
Nee ALKALOIDS ( I'ryetaUe) , ANESTHETICS
(Lot nl Aii^thetia) , ANALGESICS AND AM>DINES ,
APPETITE (Loss of ), COCA, COCAINA, (JLAUCOMA
(Treatment), HYPNOTISM (tn Cotaitus Habit) ,
INSANITY, ETIOLOGY OF (Exotomc) , INSANITY,
NATURE AND SYMPTOMS (Etioloqical Varieties,
Cotaimtm), MOUPHINOMAMA AND ALLIED DRUG
HABITS (Cocaine J/abit), NOSE, LOCAL AN-
ESTHETICS , PHARMACOLOGY , PRESCRIBING
SPINE, SURGICAL AFFECTIONS (fynnal Cocatnisa-
tion) , TOXICOLOO\ (Alkaloids and Vegetable
Poiwns, Cocaine)
COCAINE is an alkaloid which was discovered by
Nicmauu as long ago as 1860 in the leaves of
Eiylhroiylon Coca, a shrub cultivated chiefly
m Bolivia and Peru It was introduced into
clinical use by Roller in 1884 In the British
Pharmacopoeia the official picparations are the
dried leaves — Coca , extiactum cocee liquidum ,
cocama, cocainw hydrochloras , lamellae cocamec,
each of which contains -^ of a giain of the
hydrochloratc of cocaine, mjectio cocaineo
hypodermic a , unguentum cocamte , and trochisci
kramcrisc ct cocainre
The Alkaloid — Cocaine is but slightly soluble
in water. It dissolves readily m alcohol, in
melted vaseline, in castor and other fixed oils,
and in many volatile oils If heated m water it
decomposes, and the solution contains ecgonine,
benzoyl ecgonine, and benzoate of cocaine.
170
COCAINE
The Salts.— Hydrochlorate of cocaine, the
officinal salt, is readily soluble in water, but
insoluble m fats and oils.
PHYSIOLOGICAL ACTION — Local — When a
solution of hydrochlorate of cocaine is applied
to a mucous membrane it produces temporary
local anaesthesia and anaemia, which last for
ten minutes or more, according to the strength
of the solution used If applied to a turgescent
mucous membrane, it produces collapse of the
swollen structures, unless the turgescence has
been so long continued as to result m connective-
tissue hypertrophy Temporary local dilatation
of the blood-vessels may follow
When applied to the conjunctiva, slight
smarting, followed by anaesthesia, results The
pupil is dilated, an effect ascribed by Roller to
contraction of the vessels of the iris, but by
most other authorities to irritation of the
sympathetic Accommodation is impaired, but
this passes off more rapidly than the paralysis
produced by atropine
The skin is much less affected by local
application than are the mucous membranes
Internal , — Internally cocaine acts as a
stimulant, producing a sensation of exhilaration
and well-being, with increased mental and
muscular power In animals the brain, medulla,
and spinal cord are stimulated from above
downwards Largo doses produce convulsions
of cerebral origin. The sensory tracts of the
cord are paralysed, and amesthcsia results
This effect has lx»en produced m animals by the
administration of dangerous doses, but quite
recently Bier has produced a similar effect m
the human subject by the injection of small
doses (J to \ gr) directly into the cerebro-
spmal sac under conditions similar to those
required by Qmncke's exploratory puncture.
He claims that complete anaesthesia can thus bo
safely produced below the level of the nipples
He has operated thus successfully on several
patients chiefly for tuberculous bone and joint
disease of the lower extremities.
Circulatory — Cocaine produces moderate
stimulation of the hoait's action
Respiratoiy —Respiration is powerfully stimu-
lated, and its rhythm is distuibed Death
from cocaine poisoning results from paralysis
of respiration and the exhaustion produced by
the accompanying convulsions.
Large doses produce a slight rise of tempera
ture Cocaine is mainly destroyed m the body,
but may m part bo eliminated by the kidney
The amount of urine is said to be slightly
increased, and the urea to bo diminished
METHODS OP APPLICATION — The great value
of cocaine lies in its property of producing local
anaesthesia, and for this purpose various methods
of application are adopted.
For the eye aqueous solutions of the hydro-
chlorate of the strength of 2 per cent, or even
of 4 per cent, are made use of, a drop or two
of the weaker solution requiring to be applied
two or three times at intervals of three or four
minutes
For the mucous membranes stronger solutions
may bo made use of even up to 50 per cent,
but it is seldom necessary to use solutions
stronger than 5 per cent. Several applica-
tions of the weaker solutions may be made at
intervals of three or four minutes, or a small
piece of cotton wool soaked in the solution
may be left in contact with the part to bo
rendered antithetic
For application to the skin, watery solutions
are of little value, and for this purpose oily
solutions of the alkaloid should be made use of
Injected hypoderniically, anaesthesia is pro-
duced for a limited area around the puncture
A watery solution is marie use of, and the dose
as a rule should be limited to half a gram
Where possible, e g in amputation of a finger,
a ligature should bo tied round the part to be
operated on in such a way as to obviate the risk
of toxic effects from the passage of the drug
into the system
Another important method of application is
that known as the infiltration method (Schleich)
This is described m article "Anaesthetics,"
vol i p 159
USES —Local — The degree of anaesthesia
produced by cocaine when applied to the eye
is sufficient to allow of practically any opera-
tion being performed on the eyeball It meets
all the requirements that can reasonably be
expected of a local anaesthetic, and hence has
come to bo regarded m ophthalmic practice as
the anaesthetic par excellence
In nasal, aural, and throat opciations it is
of great value, and the manner of application
and other points of practical impoitaucc will be
specially referred to undei "Ear" and " Nose "
In dentistry it is useful in toothache, and is
also used to deaden the exposed pulp or dentine
before filling the cavity of a caiious tooth By
injecting a dose into the gum on each side of a
tooth the pain of extraction is greatly lessened.
By hypodeimic injection or by Schleich's in-
hltration method nearly all minor surgical
operations can be earned out painlessly
During labour it has been used to relieve
the pain of the dilating os uteri, and to relieve
spasmodic contraction due to pain
An oily solution of the alkaloid may be used
to relievo the pain of shingles, eczema, neuralgia,
pruritus, or urticaria
Acute coryza, acute pharyngitis, hay fever,
and similar conditions may be much relieved,
especially m early stages, by a spray of a watery
solution.
Internal — Cocaine is used inteinally for sea-
sickness and the vomiting of pregnancy, as a
tonic dunng convalescence, in mental exhaustion
and muscular debility, and it has been recom-
mended in alcoholism and the opium habit, but
COCAINE
171
its use in the latter cases must bo strongly con-
demned on account of the risk of development
of the cocaine habit
DRAWBACKS TO THE USE OF COCAINE — One of
the greatest dangers attending the use of cocaine
is the development of the cocaine habit This
habit is frequently secondary to morphinism,
but may be developed from the rmnhcinal use
of the drug In one of several cases which
have come under the writer's notice, the habit
developed in a chemist who was wont to resort
to a cocaine snuff to leheve a chronic nasal
catairh The "coca wines" so recklessly pressed
upon the public as useful "tonics" are also a
source of danger (see " Morphmomama and
Allied Ding Habits")
When used with caution untoward effects
are not common, but such have occasionally
occurred, especially after the too free application
of solutions to the nose and throat Symptoms
noted have been giddiness, famtness, pallor,
feebleness of the pulse, great dyspnoea, and
final collapse into unconsciousness
It is difficult to keep solutions sterile, and
it must be remembered that solutions cannot
be boiled without detitioyiiig the cocaine
EUCAINK — To obviate the disadvantages, and
even dangeis, occasionally attending the use of
cocaine, efforts have been made to produce
some substance free fiom these dm* backs
These ha\e resulted in the introduction into
practice of two synthetic products known as
eucaine, both of oxtiemely complex composition
For convenience these aio distinguished as
alpha-cucamc and beta-eucame The foirner
of these was found to be less toxic than cocaine
and to be an efficient anaesthetic, but, unfor-
tunately, when applied to delicate mucous
membiaiies it produced a great deal of smarting
and irntntion, and thus was unsuited foi
ophthalmological woik For bcta-eiicame it m
claimed that it is equal to cocaine in anaesthetic
properties, that it is much less toxic, and that
it does not cause local irritation It is soluble
in distilled water to the extent of 15 per cent,
and the solution can bo sterilised by boiling
Moreovei, the solutions keep well
Beta-em, une may bo used for all the surgical
procedures foi which cocaine is adapted, and in
solutions of fiom 2 to 10 per cent The stronger
solutions must be mode with hot water For
ophthalmological work a 2 per cent solution is
recommended It differs from cocaine m that
it produces no dilatation oi the pupil, and no
disturbance of accommodation Another point
of difference is that it causes little or no con-
traction of turgid mucous membranes, a point
which may bo an advantage or a disadvantage
according to what is desired
Cocalnlsation, Spinal. See SPINE,
SURGICAL AFFECTIONS OF (Spinal Cocamwition)
CoCCldlO8l8. — A disease common in
young rabbits, due to the presence of the spororoa,
known as coccidia, m the liver and other organs,
psoro-spcrmiasis See PARASITES (Protozoa,
Sporozoa).
COCCldlum.— There are various species
of coccidia, including the C homing C. cunicuh,
and C awum they arc all narasitic and belong to
the class sporozoa of the Protozoa , they infest
rabbits and birds, and have occasionally been
found m the liver and intestine of the human
subject See COCCIDIOSIH , PARASITES (Protozoa,
Sporozoa)
CoCCillUS In diC US.— The dried fruits
(Or KOKKOf, a berry) of Anemirta paniculata,
which contain the poisonous glucoside (?) picro-
toxme, w Inch has the formula of C16H]flO6, H2O,
or C30HMO1V or CqH1004 See TOXICOLOGY
(Attatotd* and Vegetable Poison*)
COCCUS. — ( 1 ) Cochineal, or the dried fecun-
dated female mseit G'exu/* ta<tt, contains the
glucoside carminic acid, t/lTH]SO10 and carmine,
and is used as a colouring agent (eg in the
compound tincture of cardamoms) The official
preparation is Ttnctwn Coca (dose, 5 to 15 m )
(2) A rounded or ellipsoid micro-organism (e <j
micrococcus, streptococcus, etc )
Coccyalgla or Coccyffalffla.—
Pain in the coccygeal region. See COUCYGO-
DTNIA
CoCCygeCtomy.—- Excision of the
coccyx See COTTIGODYNIA
COGCygOdynia. See also COCCYGEC-
TOMY, LABOUR, INJURIES (Pelvic Articulations).
— Definition — A painful condition of the coc-
cygeal region produced by the acts of sitting,
walking, or defteeation
Description — The structures involved may be
the coccyx, sacia coccygeal joints and ligaments,
permcal muscles attached to the bone, terminal
branches of the sacral plexus of nerves, and
probably the coccygoal gland It has to be
distinguished from a somewhat similar condition
frequently associated with certain affections of
the vul\,i, uterus, o\anes, pelvic peritoneum,
and separation of the bones at the symphysis
pubcs It is found almost exclusively in the
female sex, although cases are recorded of its
occurrence in males and child ten
Etiology — 1 Traumatism dm ing labour,
causing —
(a) Injury to the fifth sacral and coccygeal
nerves
(b) Dislocation of the sacro-coccygeal joint, or
fractal e of the coccyx
The latter may be produced by other causes,
eg falls or blows
2 Rheumatism affecting the ligaments or the
periosteum of the coccyx
172
COCCYGODYNIA
3. Neuralgia affecting the terminal branches
of the sacral plexus
Probably moat cases are of this nature
Diagnosis should be made by placing one
finger in the rectum and tho other over the
skin surface of the coccyx, when pain is pro-
duced on pressing tho bone or structures round
it, according to the part chiefly affected
Symptoms — Pain limited to tho coccyx and
neighbourhood, and aggravated by such acts as
sitting or walking.
Prognosis is favourable, although many
months may elapse before tho pain completely
subsides, and the condition is prone to recur
Treatment — Any concomitant pelvic disease
must be first attended to If there are indica-
tions of a primary inflammatory condition of
the parts affected the patient should be kept at
rest in bed, preferably in the lateral posture
Pain may be relieved by lead and opium fomen-
tations, morphia hypodenmcally, or a sup-
pository of morphia and belladonna
Laxatives should be administered to facilitate
defalcation, \vhich is frequently painful Tn
cases associated with dislocation or ankylosis of
tho sacro-coccygoal joints, massage and mani-
pulation should be tried bofoio resoiting to
operative measures If there is no lesion of
the bone the faradic current gives excellent
results, one pole being applied ovor tho sacrum
and the other over the coccyx As a rule two
to twelve applications aio sufficient Tho
application of the actual cautery over the origin
of the sacral nerve may be icsorted to if other
means fail to give relief The cases recorded
as occ mring in men and children have been
successfully tioated by anti-rheumatic remedies
Operative Tt eatment — In obstinate cases Sir
J Y Simpson recommended and carried out tho
subcutaneous division, by a tenotomy knife, of
the muscular and fibrous tissues inserted into
the sides and apex of the coccyx, with the
object of preventing any movement of the bone
When the condition is associated with a lesion
of the bone and unrelieved by other methods,
Nott first suggested tho complete extirpation of
tho bone To cairy this out a vertical incision
is made over tho posterior surface of tho bone ,
the apex is then pulled well back, allowing
the muscular attachments to be freed ; finally,
tho bone is separated at tho sacro-coccygoal
point
Both those latter methods are rarely necessary,
and cases are recorded where the pain recurred
oven after operative treatment
CpCCyx. — Tho four terminal vertebra) or
tho single bone formed by their coalescence ,
the name is derived from Or KOJCJCV£, a cuckoo,
it being supposed that the bone has tho shape
of that bird's beak. See COCCYGODYNIA ;
LABOUR, PROLONGED , LABOUR, INJURIES TO THE
GENERATIVE ORGANS (Pelmc Articulations),
RECTUM, DISEASES OF (Kraske's Operation) ,
RECTUM, DISEASES OF THE (Coccygeal Pain)
Cochin China Ulcor. See SKIN
DISEASES OF TUB TROPICS (Tropical Phagedcena).
Cochineal. &e Coccus.
Cochlea. — Part of the internal ear, a
spiral cavity (Or icoxAtas, a snail) in the osseous
labyrinth (osseous cochlea), with membranous
canals in it, one of which is named the scala
media or membranous cochlea, and contains the
organ of Corti See BRAIN, PHYSIOLOGY OF
(Eighth Nerve) , PHYSIOLOGY, HEARING (Internal
Ear)
Cochleare. — A spoon See PRESCRIBING
This measure vanes somewhat, containing from
£ fl dr to J fl oz of fluid, variations which
are indicated by the expressions tea-spoon,
dessert - spoon, and table-spoon Cochleatim
means " by spoonfuls "
Cock'8 Operation.— A method of per-
forming external urethrotomy See URETHRA,
DISEASES OF (Stnctute, Treatment)
Codes. — Having one eye, monoculiih,
monophthahnus , derived fiom Gr KWCAW^, a
Cyclops or Round-Eye
COCOa. — The beverage made horn the
seeds of Theobroma. cacao , also the fruit of
Cocoa mi of eta See DIET (/females), INVALID
FEEDING (Cookery in Diabete*, Cocoa-Nut CaLe*)
PHYSIOLOGY, FOOD AND DIGESTION (Tea, Coffee,
Cocoa)
CoCOOn Silk. See, DhUMATiTis TRAU-
MATICA ET VENENATA (Eczema, Causal Ayents,
Animal)
— One of the alkaloids
(C20H25N04) existing in opium (</ v )
Code! n a. — An alkaloid (methylmorphme,
C,rH18(CH8)NO8, H20) obtained from opium or
moiphmc The doso of Codeina and of Codeince
Phosph<is is J to 2 grains Thei o is an oifacial
preparation of Codemee Phosphas, the Synipus
Codenup, which contains a J grain of the
phosphate in each fluid drachm (dose, J to 2
fl dr) See ALKALOIDS, ANALGESICS, OPIUM,
PHARMACOLOGY
Cod-liver OIL — Oleum Morrhuw or tho
oil extracted from the liver of the cod (Gadus
morrhva) It has a complex composition, con-
taining olcin, palmitin, myristm, stearin, fatty
acids (oleic, palmitic, and stearic), trimethyl-
amme, tiaces of iodine and bromine, and alka-
loids, such as morrhume (C1QH27N8), asellinc
(C^HggNJ, and gaduine Its fishy smell prevents
its external use, but it is given internally
frequently m phthisis, tubercular affections,
rickets, etc. The dose is 1 to 4 fl dr., and it
COD-LIVER OIL
173
may bo given as an emulsion, with malt, with
iron, and m other ways See PHARMACOLOGY ,
PRESCRIBING, etc.
COBlO- or CoellO-.— In compound words
icelo- or catlio- (from Gr KofAos, hollow) signifies
" relating to the abdomen." The caeliac a/ettum,
for instance, is an intestinal disoidcr of young
children in which the stools are pale, bulky,
loose, and porndgy, in which there is wasting,
pallor, and absence of fever, and in which death
is not an uncommon termination, although it
may be long delayed Ccehadetphm is a teiato-
logical type of double monster m which the
twins are united by their abdomens Coplwyta
is gout in the abdomen Cwliocludasis is a
relaxed state of the abdominal walls Coeliocyeiis
is cctopic picgnancy of the abdominal type
Ctrlwdyma is pain in the abdomen CailtowFiivis
is an open state (congenital) of tho abdomen
Cceltosteywuu is constipation Cueliotoniy is
opening into tho abdominal cavity for diagnostic
or operative pin poses See ABDOMEN, INJURIES
OF (Treatment) , LABOUR, OPERATIONS (Ctfsarean
Nation), OVARIES, DISEASES OF (Ovariotomy),
etc Caelom is the body-cavity or space between
the two layers of the mcsoblast Ste Fovrus
A\D O\UM, DEVELOPMENT.
CoenadelpllUS. — From Gr KOIVOS,
common, and a&A</>os, brother — is that terato-
logical type of united twins in which the heait
01 liver is common to both
CcenSBStheSlS.— The feeling of wean-
ness and lassitude or of spiighthness, without
the usual exciting causes (muscular woik, etc ) ,
or the vague consciousness of being, without
the evidence supplied by the special senses
Coenurus Cerebral is. — From Gr
Koiyos, common, and o/yxi, a tail , tho vesicular
stage of the Trenm ctenurus See PARASITES
(Cestodes, Tajjeworms).
Coffee* See CAFFHINIO ACID , CAFFEINA,
DIET (JlewKir/ei) , NEURASTHENIA (Ttealmenti
Preventive) , PHYSIOLOGY, FOOD AND DIGESTION
(Tea, Cofee, Cocoa), TEMPERATURE (Diurnal
Variations)
Coffee • Grou nd Vorn Itl ntf.— The
vomiting of blood altered in appeal ance by the
action of the gastric juices See STOMACH AND
DUODENUM, DISEASES OF (Ulcer , Symptoms)
Coffin -Birth.— Birth of the infant after
tho death of the mother (poit-mortem jMrtuiir
twn), duo probably to the presence of putre-
factive gases in the abdomen
Coffin ism. — A mode of treatment of
disease, so called after a Dr Coffin, who practised
it , the drugs given wore chiefly cayenne pepper
and lobelia inflata
See ALCOIIOL (Spirits, Brandy).
Cogwheel Respiration.— A jerky
or wavy form of inspiration (in deep respiration)
noted on auscultation in cases of pulmonary
tuberculosis, etc See CHEST, CLINICAL INVES-
TIGATION OF
Cohn helm'S Thcfory. — The theory
that neoplasms 01 iginate in cell " rests " present
m the tissues before birth and lying latent till
adult life , it was supposed that the discovery
of tho microbic oiigm of some tumours had dii^
credited this thooiy, but m its modified modcrm
foim (theory of embryomata) it has many
supporters See aho ADRENAL G LANDS (Tumours,
Adtenal" Rests")
Coif. See CAUL
Col 1 1 ng Of Cord. See LABOUR, FAULTS
IN THE PASSENGER (Cord) , LABOUR, ACCIDENTAL
COMPI ICATIONS (Cods oj t/w Cord)
Coin -Sound. — The metallic echoing
sound heard in pncumothorax, when one observer
listens over the back of the chest \vhile another
sharply tips a coin placed on the front of the
chest See BRUIT D'AIRAIN
ColtlJS. — Sexual intercourse (from Latin
coeoy to come together) See MEDICINE, FOREN-
SIC (Jiajte) , PREGNANC*, DIAGNOSIS (Date of
GWws), PREGNANC\, MANAGEMENT (Coitus
dunntj Piegnamy) , VICE (Sexual System^
Coke. See Toxicoix)uv (Gaseous Poison*,
Carbon Jfotwfide)
Cola. 'SVeKoLA
ColchlClne.— An alkaloid (?), the active
principle of colclncum (</v), ebullition with
acidulated water is said to conveit it into
colchiccme(C21H22(OH)N05) and methyl alcohol ,
according to Xeisel tho formula of colchicme is
C^H^OCH^NO... See ALKALOIDS ( Vegetable) ,
COLCHICUM , TOXICOIXJOY (Alkaloids, Colchicum)
Colon lOU m. See GOUT , PHA RMACOLOG Y ,
PRESCRIBING , TOXICOLOGY (Colchirum) — Both
tho corm and the seeds of Colchuumautumnale
are official The active principle is Colchiane,
a yello\v crystalline alkaloid Vnaf) ine is also
present in traces The seeds contain a greater
propoition of tho actrve alkaloid than the corm,
and possess in addition a volatile oil The pre-
parations from Colchwi cot //IMA are — 1 Extrac-
tum Colchici Dose — J-l gi 2 Vinum Colchici.
Dow — 10-30 m From Colthici semina is pre-
pared Tmctura Colchici Sominum Dose — 5-1 5 m
Colchicum is a specific for gout, and is hardly
ever used except m this disease Given during
an acute attack, it lessons the pain and cuts
short tho attack. In smaller doses in the
174
COLCHICUM
See HIDROPAT
intervals it lessens the seventy and diminishes
the frequency of the seizures. It is also used
in a great vanety of conditions which are, or arc
supposed to be, of a gouty nature It has been
recommended in small doses as an addition to
an aperient pill m chrome articular rheumatism
The beneficial effects of this ding probably
depend on an increased excretion of toxic pro-
ducts resulting from stimulation of the hepatic
and intestinal functions
Cold. See ANTIPYRETICS AND ANTIPYRETIC
MEASURES (Abdication of Cold) , HEMORRHAGE
(Local Treatment, Cold and Hot Watei) , H\DRO-
PATUY (Cold Pack) , MEDICINE, FORENSIC (Death
from Cold), PUERPERIUM, PATHOLOGY (Para-
metntis and Peritonitis, Ire-bay) , SfOMACH AND
DUODENUM, DISEASES OF (Ueneial Etiology, Cold
and Damp) , TEMPERATURE (Treatment of Fevet,
ColdJtath)
Cold Cream.— Cold crean^^ the ^a-
guentnm Aqua? Rosa*, an official pi ^**ra"0ii of
the Oil of Rose (q v.)
Cold Pack.
Cold)
Cold SpOtS. See PinHlOLOtiY/'$"fe>
(Temperature Sense)
ColOCtomy.— Excision of a part of the
colon See COION
ColeoptOSlS.— Prolapse ot the vaginal
walls with 01 without prolapse of the uterus
(Gr jcoAeo?, vagina, and TTTOXTIS, descent)
ColOOrrhexiS.— Hupturo of the vagina
(Gr icoAeos, vagina, and /w}£«, rupture)
ColOO8tegnOSl8.—Narrowiu£ or con-
striction of the vagina (Gr KoA«fe, vagina, and
trriyvwrts, constriction)
ColOy'8 Fluid. — A mixture of the
streptococcus of erysipelas with bacillus pro-
digiosus, grown together in the same broth, and
injected in oases of malignant growth (e</
sarcoma) when operation is impossible See
THERAPEUTICS, SERUM THERAPY (Coley's Fluid) ,
TUMOURS, INOPERABLE, TREATMENT OF (Sactetio-
Therapy)
CollC. See APPENDIX VERMIFORMIS (Ap-
jxrruhcitis, Symptoms), DEVONSHIUE COLIC, GALL-
BLADDER AND BILE Duci^, DISEASES OF (Gall-
Stones) , GASTROINTESTINAL DISORDERS OP IN-
FANCY (Diyestion, Flatulence, and Colic), KIDNEY,
SURGICAL AFFECTIONS OF (Movable and Floating
Kidney, Pain), LIVER, DISEASES OF (Hepatoptosti,
Symptom*), MYIAHIS (Myiasis Intestinahs) ,
CEaopiiAouH (Inflammation), PANCREAS, DISEASES
OF (Cyst, Symptoms) , TOXICOLOGY (Chronic Lead
Poisoning), TRADES, DANGEROUS (Lead Potson-
%)— Under normal conditions the muscular
coat of the digestive tract performs its functions
of mixing and propelling food from the stomach
downwards, and of finally expelling the faces,
painlessly , but, under numerous abnormal con-
ditions, its gentle, painless, and harmonious
working may be roused into violent, painful,
and irregular action, the symptoms of which are
designated by the term colic, from the Greek
KwA-ov) Colic, as ordinal ily understood, may
therefore be defined as abdominal pain due to
spasmodic and painful contraction of the ali-
mentary musculature Other hollow tubes or
hollow organs may be the seat of similar morbid
action, and may exhibit like symptoms, and the
oiigmal teirn has been extended to the gall-
bladder and bile-ducts (hepatic colic), and to
the kiducv and ureter (renal colic) But this
aiticle will deal solely with colic as occnrimg m
the musculatuie of the digestive tract
SYMi'ioAt* — The essential and outstanding
symptom is pain, located m the abdomen,
leputtent or intermittent, wiithmg or twisting
in Character, and generally relieved by pressure
Its ftHiset may bo sudden or preceded by pre-
moinr*tory uneasiness It may be localised to a
par'iicular pait of the abdomen, but if severe,
tv'.. oiigm cannot be defined, and it is felt gen-
prally over the abdomen with its maximum
around the umbilicus It is spasmodic, coming
in waves, shorter 01 longei in dmatiou, and
rising from the level of complete absence of
suffering, or of more or less persistent uneasiness
It vanes m severity from beaiable griping to
agonising spasm, and in duration fiom a few
minutes to several days As in all abdominal
pain, the patient intuitively flexes the tiunk
and draws up the limbs, but, as pleasure genci-
ally lelieves rather than aggiavates his suffei-
nig, he indulges the desiie to move 01 roll about,
at the same time applying piessurc in vanous
ways, such as nibbing by hand or loaning against
a pillow Where thoio is considerable bowel
distension or associated inflammation, pressure
aggiavates the suffering The pain is of a
pecuhaily depressing character, the face is pale
and indicative of suffenug, the skin is cool and
possibly moist, the pulse is normal, or weakened
and slowed rather than quickened, the tempera-
ture is not rawed, the bowels may be seen, felt,
and heard to bo m excited peristalsis, vomiting
may or may not be piesent, the bowels may be
obstinately confined, or enabled sooner or later
to expel their gaseous or other contents with
gratifying relief to the distressing symptoms
If the cause of the colic be towards the anus the
pam is associated with a bearing down and
expulsive desire. Vomited matters are at first
from the stomach, but eventually, when the
cause of the colic is bowel obstruction, they are
from the bowels The abdomen may be retracted
or distended according to the amount and
character of the bowel contents, and the
condition of the intestinal and abdominal
COLIC
175
musculature The breathing is interfered with
according to the degree of associated contraction
of the respiratory muscles
PATHOLOGY — The essence of colic is excessive
conti action of the non-striated fibres that form
the alimentary musculature, and it has, as its
analogue, the tetanic conti action of striated
muscle that gives rise to cramp The alimentary
canal possesses within itself, independently
of the central nervous system, the nervous
mechanism necessary foi peristalsis which can
be directly stimulated But the bowel move-
ments are also influenced and secuied by stimuli
acting through the motor or augiuentor ^agu&,
leflexly or from the ceiebial centres Hence
the abnormal or excessive stimuli that load to
colic may be local, as they generally are, or they
may be distant, acting reflexly or diicctly from
the cerebral centres The pain is not a
neuralgia in the ordinary sense of the term,
but is caused by pressure on nerves from severe
muscular contraction As the splanchnic nerves
inhibit peristalsis they can have no causative
influence on colic
The inclusion of visceral neuralgia under the
term colic is undesirable
DIAGNOSIS — The diagnosis of colic would be
comparatively easy were it not frequently asso-
ciated with ailments which complicate and ob-
scure its manifestations It must be diagnosed
from othci diseases, from othei colics, and colic
occurimg in one part of the alimentary canal
must be differentiated fiom colic in another
1 From other diseases —
(a) Inflammation — In inflammation the chief
distinguishing symptoms are that the pain is
increased on pressure, that it is more or less
constant, and that fever is present as shown by
quickened pulse, hot skin, and raised temperature
(6) tfemalgia — In neuralgia the pain is
shooting or stabbing in charactci, tends to dait
in various directions, to be increased rather
than relieved by prossuic, and to be associated
with superhcial hypertesthotic areas There is a
history sufficient to account for lowered health,
and there are present other signs of the neurotic
temperament
(c) Angina Pectmis — Certain cases of angina
pectoris are difficult to distinguish from ab-
dominal colic, and have to be kept in view in
making a diagnosis
2 From other colics (Hepatic, Renal, Bladder,
Uterine) —
(d) In Jtepatic colic the pain is in the upper
part of the abdomen, and is towards the right
side and right shoulder Excited gastric or
intestinal peristalsis is absent There may be
the history of previous attacks. After an attack
there is tenderness on pressure over the gall-
bladder. There may be jaundice, and, if gall-
stones be expelled, they are to be found in the
stools.
In renal colic the pain is m one or other flank ;
it shoots down towards the bladder and into the
penis and testicle , it is associated \vith frequent
desire to micturate, and possibly with the expul-
sion of gravel or calculi
In strangury the pain is confined to the loviei
part of the abdomen, and is associated with
urmaiy urgency
In colic in the ummpregn^ted uterus the pain
is m the hypogastrium, and it occurs in relation
to the menstrual pet tod
The physiological colic of an impregnated
uterus needs only to be ref cried to
In Fallopian tube colic (one manifestation of
Mittelschrnerz) pain occurs in one or other
ovaiiun region, in mid-menstrual period, there
limy IKJ sudden, clear, leucorrhooal discharge,
and fulness at painful side may be found on
-vaginal examination
.3 Colic in the alimentary canal may be more
or less confined to a particulai portion of its
area
In gasttic colic pain and distension occur in
the upper central part of the abdomen The
jiercussion note is stated to be moic prolonged
and of a lower pitch than over the colon The
chaiacteristic intestinal movements ate absent
Eructation of gas attended by iclicf, also vomit-
ing, moio freely occur
In intettmal colic the symptoms previously
described are characteristic, colic m the lower
bowel being specially attended by teuesuius
AppendiLiilar coin — In a typical case it occurs
at somewhat regulai intervals, say, from three
weeks to three months While at its height the
pain is felt over the abdomen generally, it
begins and ends m the right flank, tenderness
to pressure being located in the region of the
appendix Vomiting occurs, and the patient
may imagine he suffers from bilious attacks, all
the more that they may recui for a period of
years even The attack lasts for a few hours,
and is not in the first instance associated with
fevoiishness But soonei or later inflammation
complicates the situation The writer believes
from clinical experience that appendicular colic
is compaiatnely frequent, but that as many of
the attacks are mild, they aio uniecogmsed by
patient and physician alike Being mild, the
operating surgeon sees nothing of thorn, in
severer cases ho deals with them only aftei
inflammation has complicated and obscured the
clinical picture
EIIOIOGY — Colic, like cough, being a symptom
rather than a disease, is caused by and is asso-
ciated \vith numerous morbid conditions It is
the expiession of a normal function acting m
excess m response to undue stimulation, and
having as its mam object the overcoming of
unusual difficulty or the expulsion of an
irritant
In certain individuals the intestinal muscula-
ture is more easily stimulated to excessive action
than m others. There is a predisposition to
176
COLIC
colic, the same degree of stimulus having vastly
different effects m different individuals. The
exciting causes may be within the alimentary
tube, in its wall, or outside altogether. The
contents may act by their quantity or by their
quality, or by both Mere quantity by over-
distension will over-stimulate, e.g accumulation
of gas or of ffficcs from constipation, or from the
vanous forms of obstruction, such aa simple and
malignant stricture, intussusception, volvulus,
internal strangulation from bands, peritoneal
adhesions and kinks, intestinal concretions, large
gall -stones, coiled -up bundles of worms, and
henna. Exciting quality of contents is exem-
plified by irritating articles of diet, themselves
indigestible or containing ptomaine poison, by
irritant poisons, by irritating purgative medicine,
by irritating results of evil digestion Exciting
causes situated in the intestinal wall are seen in
local injury, as from intussusception, hernia,
etc., acting primarily by direct local effect, and,
secondly, by over-distension behind , m ulcera-
tion, malignant, simple, tuberculous, or dysen-
teric, m inflammation, catarrhal, enteric, or
poritomtic, where the pain is partly to be
accounted for by excited peristalsis Causes
outside the intestinal canal find their illustration
in exposure to cold, in dentition, in mental
anxiety or emotion, in disease of the spinal cord
as locomotor ataxia, but these are associated
rather with diarrhoja or neuralgia than with
colic
It has not yet been satisfactorily demonstrated
how the/waon. of lead produces colic. It prob-
ably docs not act through constipation or
through organic disease of the sympathetic, but
whether it acts directly on the intestinal muscu-
lature or nervous ganglia, or by leading to con-
tiaction of the blood-vessels, is a moot question
T RE ATM EN i — Whatever the cause, pain de-
mands relief, all the more that, if very severe, it
may load to serious collapse, while the excited
peristalsis, of which it is a symptom, has been
found to cause rupture of the bowel When
intense, moiphia should be injected subcutane-
ously, and whiffs of chloroform given until it
has had time to act When less severe a hot
bath or a warm poultice applied over the
abdomen, with some sedative and antispasmodic,
as morphia and chloric ether internally, suffices
Pain being relieved there is time to examine
quietly into the case and to determine the cause,
and upon the cause depends the scientific and
successful treatment of the condition The
sedative, moreover, when given in an appropriate
dobe, paves the way by quieting irregular spasm
for that regular and harmonious action of the
musculature which leads to success In gastric
colic the stomach must be emptied. If it fail to
do so by its own efforts, emesis must bo en-
couraged, or the stomach tube used
In intestinal colic of any gravity, obscurity,
or permanence, the physician should, without
undue delay, associate himself with a surgeon.
Where mere mechanical causes can be excluded,
such as hernia, volvulus, etc., nature's attempt
to empty the bowels must be assisted by the
immediate use of rectal injections, and by the
administration, where vomiting is not actively
present, of non-irritating purgatives, such as
castor oil, calomel, or salines
Where ftecal accumulation is v\ ithm reach it
is generally necessary to combine the use of the
finger with the action of the enema in order to
get rid of it. When legitimate eftorts have
failed to empty the bowel and give permanent
relief, there should be no undue delay in decid-
ing the question in consultation with a burgeon,
whether the abdomen is to be opened or not for
the detection and removal of any obstruction, or
for the making of an artificial anus above the
recognised seat of obstruction
Appendicular colic must be dealt with by
removal of the appendix in a quiet interval.
Until relief is obtained, in acute cases it is
practically useless to feed the patient Ice to
suck or hot water to sip in order to relieve
thn&t should be given
Where recurring attacks occui from mal-
digestion, as m bottle-feeding of infants, preven-
tion must be secured by proper dieting
Where colicky attacks are caused by catarrh
or by ulccration of the bowel, appropriate dieteti-
cal and medicinal treatment is necessary
The colic said to be associated with the first
stage of peritonitis, and the colics from causes
outside the alimentary canal, acting reflexly, can
only be relieved by sedative treatment such as
morphia or the hot bath
Col lea PlCtonum.— Lead colic, especi-
ally common m Poitori (hence the name)
Colitis. — Inflammation of the mucous
membrane and also of the deeper-seated parts of
the colon *SVe COLON, DISEASES OF See also
APPBNDIX VERMIMMMIS (Appendicitis, Diaynovs),
CHOLERA NOSIRAH (DiaynoMs) , FACES (in Ulcer-
ative Colitis) , SPOOLS (Inteshnal Sand and
Gtavel) j TYPHOID FEVER (Diagnosis from, Ulcer-
ahve Colitis)
Collagen. — A substance of which non-
elastic fibres are composed, allied to the proteids
(but not yielding tyrosin when decomposed),
having a great affinity for carmine , when boiled
it takes up water to form gelatin (Gr KoAAa,
glue, ytwav, to form ) See PHYSIOLOGY, TISSUES
(Connective Tissues)
Collapse. — The loss, more or less sudden,
or the great weakening, of most of the signs of
vital activity, occurring either as the last stage
of shock or as the result of a severe disease (e.y
cholera) or a long-continued one (typhoid fever)
See SHOCK (Definition). See also CUOLBRA,
EPIDEMIC (Treatment, Collapse), LABOUR, POST-
COLLAPSE
177
PARTUM HEMORRHAGE (Pott-Jut morrhagtc Col-
lapse), LABOUR, IJ.JUIUES TO THE GENERATIVE
ORGANS (Rupture of Uterus) , LABOUR, INJURIES
TO THE GENERATIVE ORGANS (Acute Invasion of
Uterus) } PANCREAS, DISEASES OF (Ilvenunrhage
in) , PUEHPERIUM, PATHOLOGY (Sudden Death) ,
TEMPERATURE (Alteration*, Dejnea*ton)
Codes' Fracture. See WRIST -JOINT
INJURIES (Fracture* of the Bone* of the For<-
aim)
CollOS' Law.— The fact that a woman
(not apparently buffering from syphilis) who has
given birth to a syphilitic child may buckle it
without risk of becoming infected , it is sup-
posed to be due to maternal immunisation by
small doses of the syphilitic virus received
through the placental connections , it is not an
absolute law, for exceptions have been reported
(<J Novy, Zenttlbl } Uynak xxx 590, 1906)
tier BEAUMES' LAW, PREGNANCY, AFFECTIONS
AND COMPLICATIONS (Syjthilut)
Co I ley's Operation. See PALME,
CLEFT (Ojjemtive Treatment)
Collier's Bronchitis, See BRONCHI,
BRONCIIH is (Cfuomc)
Colllquatlve Necrosis.— A post-
nccrotic tissue-change in which softening and
liquefaction without decomposition occur, eg 111
the cerebral tissues after embolism
CollOdla. — Solutions of pyroxylin or
soluble gun cotton (C0Hb(NO2)p5) m ether or in
.1 nnxtuie of ether and alcohol" See COLLODION
Collodion.— The ofhcial collodnim is a
solution of dimtro-celluloso (CbHs(NO,j)2Or)) 01
pyroxylin, in ethei and alcohol, from this,
(ollodium flexile is obtained by the addition of
Canada balsam and castor oil Co/lodnim vest-
can* contain!) 1 part of pyioxyliu dissolved in 10
paits of Liquor Epispasticus Collodion, when
painted on the skin, rapidly dries and forms a
protective film , so it is used for closing small
wounds, for attaching dressings, for protecting
irritated parts from the air, and for the local
application of medicines, such as canthandea,
carbolic acid, lodoform, mercury, creosote, iron,
lead, tannic acid, etc See ASEPTIC TREATMENT,
COLLOID , GOS&YPIUM , PHARMACOLOGY , PRE-
SCRIBING
Colloid Degeneration. -The for-
mation of a semi-solid, structureless, jelly like
substance (colloid) m epithelial cells, especially
in those of the thyioid gland and in cancers,
colloid has no fixed chemical constitution, but it
is not identical with mucm (for it is precipitated
by tannic acid, but not by alcohol and acetic
acid). See CHOROID, DISEASES OF (Ckoroidal
Degeneration) , FLUIDS, EXAMINATION or (Ovat vin
Cy*ts) , PERITONEUM, TUMOURS (Colloid Cancer) ,
STOMACH AND DUODENUM, DISEASES (New Growths,
Carctnomata).
Col lold M i 1 1 U m. See TUMOURS OF i HE
SKIN (Benufti, Colloid-Mtlmm)
Colloid, Styptic.— A preparation con-
taining tannic acid (20 parjte), alcohol (5 parts),
stronger ether (20 parts), and collodion (55
parts) , xylo-styptic ether (US Pharmacopoeia).
Collunarla.— Nasal douches or washes
(Latin, coll no, I wash)
Collutorlum.— A mouth wash or gargle
(Latin, colluo, I
Collyria. — Eye-salves or eye-u ashes (Gr
KoAAi'/o'ov, an eye-salve)
ColOboma. — Coloboma (Gr. KoAo/?o;r
mutilated) signifies a defect, and more especially
a congenital hssiue or defect of some part of the
eye, e y of the eyelid (C jtafpebro' or blepha.ro-
coloboma), of the iris (C trirfcf), of the choroid
(C cAotcnrfai), of the lens (C lentil), or of the
letma (C tettnrp) Fissure of the lobule of the
ear is known as Coloboma loftuh See CIIKEK,
FISSURE OF , CIIOROID, DISEASES OF (Congenital
Afe<tions) , E\KLIDH, AFFECTIONS OF (Congenital
Defect*), IRIS AND CILIARY BODIES (Congenital
Abnoinuihtiex of the Inn), LENS, CRYSTALLINE
(Caloffttma) , MFXTAL DEFICIENCY (Cololonia
utdi<t in) , PALAIK (Congenital Malformations of
Mouth), RETINA AND OPTIC NERVE (Congenital
Almotmalitie*)
ColOCynth. See PiiAUMAroi/Kn , TOXI-
COLOGY (Abort i fm tent*) — Colocynthidis Pulpa is
del ived ti oiu Citrullus colocyntht*, the bitter apple
It contains coloci/jif/nn, a neutral crystalline
glucoside, and various lesmous substances Its
piej tat at i on* are — 1 Extractum Colocyuthidis
CompOHitum Contains also Barbados aloes and
scammony Dose — 2-8 gr 2 Pilnla Colocyn-
thidis C'omposita Contains also Barbados aloes
and scammony Do»e — 4-8 gr 3 Pilula
Colocynthidis ot Hyoscyauu Same foimula as
the last with extract of hyoscyamus added
Colocyrth is a very efficient and widely used
h^diagogue cathaitic It causes a large increase
of intestinal secretion, and stimulates the whole
length of the bo\\el It causes considerable
griping if given alone, and the pill with hyoscy-
amus IH therefore most commonly employed.
It is too nutating to bo given repeatedly over
long pciiods , but whenever a free purging of
the whole intestinal tract is required no bettor
drug is to be found
Colon, Diseases of.
INFLAMMATION AND ULCER ATION 178
SIMPIE COLITIS 178
MEMBRANOUS COLD is 179
12
178
COLON, DISEASES OF
ULCBRATIVB COLITIS
OTHER VARIETIES
DILATATION OF
SACOULATION OF
INJURIES OF
MALFORMATIONS OF
PIGMENTATION OF .
MALIGNANT DISEASE
181
183
184
185
185
185
185
185
See also ABDOMEN, INJURIES OF (Lenom of the
Intestine) , GASTRO - INTESTINAL DISORDERS OF
INFANCY (Conyenital Dilatation of t/ie Colon) ,
INTESTINES, SURGICAL AFFECTIONS OF (8h ittuiei),
LIVER, TROPICAL ABSCESS (Rupture into Colon) ,
PHYSIOLOGY, FOOD AND DIGESIION (Latge In-
testine); TYPHOID FKSER (Xymptonw, "Bell
Sound")
INFLAMMATION AND ULCERATIOV — 1 SIMPLE
COLITIS. — The colon may be the seat of a simple
catarrhal inflammation comparable to a gastritis
or a bronchitis If in such a case the inflamma-
tion extends low enough, a rectal examination
with a speculum will show thu mucous mem-
brane to be intensely injected, of a light red
colour, swollen, and secreting A thick mucus
The description ol Wilks and Moxon gives a
very good picture of the state of things seen
after death They mention a "case attended
by discharge ot mucus and blood where after
death the whole internal surface of the colon
presented a highly vascular soft red surface
covered with tenacious mucus or adherent
lymph, and hero and there showing a few minute
points of ulccration The coats also \vcre much
swollen by exudation into the mucous and sub-
mucous tissues "
There are two varieties of simple colitis, viz
that which occurs either by extension from
neighbouring parts or in association with some
grave morbid condition, and that winch is
unassociated with any other serious malady
This, which has been called acute ja imtiry colitit>,
will now be described
Symptoms — The mam symptom is diairhooa,
which may come on suddenly , there is much
mucus in the stools, and often blood also, even
in considerable quantities At first there may
be absolutely no fsocal matter, but as the patient
improves the motions contain more ftcces and
less mucus The blood is mostly fluid and but
little changed, so that vo may infer that it has
but recently left the vessels, and has come,
therefore, from the large intestine Often the
mucus is in little lumps Triple phosphate
crystals may be seen on microscopical examina-
tion, and, rnoie rarely, oxalate of lime, cholestenn,
and Churcot's crystals The bowels may be
open many times a day, and although tenesmus
is not a striking feature, it may bo present A
rectal examination reveals nothing abnormal
except that the mucous membrane may feel a
little rough. Abdominal pain is a very common
symptom, it comes on in paroxysms, often
associated with defalcation, but it bears no
relationship to food It is of a griping character,
often very severe, and it nearly always follows
the com so of the colon Between the attacks
the patient may be free, but he sometimes com-
plains of a dull pain Abdominal tenderness is
usually present , a very common seat for it is
over the vymaidflexwe, but the whole colon, or
oven the whole abdomen, may be tender There
may be considerable pyioxia even when there is
much dianhcca and loss of blood The pulse is
rapid, and in a severe case small, soft, and
running The abdomen is not much distended,
and sometimes nausea, vomiting, and loss of
appetite are present The tongue is fin red, and
the fin is nearly always a piuo white, while in
many diseases with which colitis might be con-
founded it is a brownish white Theie is often
much mental depiession , the sufferer fioni this
disease exaggerates trifles and takes a gloomy
\iew of life In some cases the neurotic clement
is very marked, and we aie foicibly reminded of
the chronic neuiotic dyspeptic Many of those
neurotic patients are men who may 1x3 said
almost to live foi their illness, and they are
usually most difficult to cure
Simple colitis is by no means always so scveie
as this description might lead the leader to
expect, but the difference is only one of degree
The majonty of cases are mild, but, on the other
hand, the diairhoua may be uncontiollablo, and
the patient may die from exhaustion
The treatment consists in keeping the patient
absolutely m bed until the diarrhoea has stopped,
the motions are well ioimcd, blood is no longei
passed, and the tempoiatuie is noimal , and
longer still if he has had a severe attack
Warmth to the abdomen is very desirable lie
should consume nothing but milk, and should
not take moio than two fluid ounces .it a time
The total daily amount will depend upon the
acutencss of the attack and the gcneial condition
of the patient A good way of checking the
diarrhoea is to give some laudanum or chloiodyne
with fifteen 01 twenty grains of carbonate of
bismuth suspended in some mucilage every four
hours, the compound kino powdui is also very
valuable If these drugs fail, a starch and
opium enema will often succeed Should opium
bo foi any reason coutia-mdicated, compound
catechu powdei is veiy useful But all astrin-
gent chugs should be omitted as soon as pos-
sible, for the constipation that follows colitis
is often veiy troublesome It is best relieved
by a rectal injection of six 01 eight ounces of
warm olive oil or a diachin of glycenne A
long holiday among new and interesting sur-
roundings greatly aids the convalescence in
neuiotic cases
The diagnosis is riot usually difficult The
disease is known from ulcetative colitis by its
sudden onset, by the large amount of mucus in
the motions, by the fact that blood appears
COLON, DISEASES OF
179
early, and also by the fact that under appro-
priate treatment the case usually yields In
England acute dysentery is hardly likely to lead
to a mistake, but the meat-washing character of
the stools, the burning pain in the rectum, the
intense tenesmus, and tho constant desire to go
to stool even when nothing is passed, should
prevent mistake It is, however, important to
remember that in England wo often see severe
cases of colitis in persons who hav*> had dybentery
abroad, and under strict treatment these cases
recover completely Entenca, malignant disease
of the bowel, and arsenical poisoning may all
give rise to errors of diagnosis.
The prognosis IH as a rule good, and acute
cases are noon well, but in cases that have been
allowed to become chronic — and often the disease
has lasted many months before it is taken
seriously in hand — the patients require rest in
bed and milk diet for many weeks before re-
covery is complete, and it should be remem-
bered that few patients are kept in bed too long,
but that many arc not kept in bed long enough
The more ne m otic a patient is, the worse is the
prognosis, and some neurotic women seem never
to lose the disease in spite of the most careful
treatment
That colitis which occurs either by extension
from neighbouring parts or in association w ith
some giave morbid condition need not detain us
long, for it is generally marked by the diseases
of which it foims a part I ha\e come across
the following varieties —
I have seen the colon actually inflamed in a
case in which thcie w.is acute gastittis duo to
the swelling of an acid The stomach was in
contact with the colon, and the colitis appeared
to be due to direct extension of inflammation,
for all coats were implicated
Sometimes direct irritation, such as enormous
doiei of puiyatives, will cause colitis, and in
some cases of arsenical or mercury poisoning
colitis is found w hich is probably duo to excre-
tion of the metal into the large intestine after
it has been absorbed higher up in the alimentary
canal
Acute colitis may bo associated with septic or
pyaemic conditions As an instance 1 may men-
tion the case of a woman who had pelvic
abscesses and peritonitis following gonoirhcea.
She died from exhaustion In tho caecum and
foi two feet beyond it the mucous membrane
was sloughing, and from beyond this to the anus
the colon was acutely inflamed, its walls were
O3dematous and thickened, its mucous surface
was greyish yellow with patches of submucous
hemorrhage ; the mucous membrane was separ-
ating m shreds in many places
Acute colitis is a rare complication of Brig fit's
cfejeav, and it may bo that this form should be
regarded as the early stage of ulccrative colitis,
which is a recognised complication of Bright's
disease. This form of acute colitis is often over-
looked because the diarrhoea due to it may bo
attributed to the purgatives so often given in
Bright's disease, to uraemia, and very little stress
can be laid upon blood in the motions, because
patients with Bright's disease may bleed from
then intestinal tiact
Colitis may in very rare cases be associated
with pneumonia, and occasionally a lardateous
colon becomes acutely inflamed
2 MEMBRANOUS COLITIS — Two distinct varie-
ties exist, one which might be termed dyspeptic
membranous colttii, and another which is always
associated with some other grave condition, or is
due to direct injury, and therefore might be called
secondary mem/tranous colitis It is not usual
to include under membranous colitis those cases
of constipation in whuh, when the bowels are
open, shreds of coherent mucus arc passed with
or without hard masses of ftecal matter, such
cases are common enough
Dyspeptic mcmbianous colitis is so called
because the suffereis from it complain much of
dyspepsia and they pass membranes from the
anus
The patients are usually over twenty years of
age , tho disease is commoner in women than in
men, and in private than in hospital practice
In children it is excessively rare, for Edwards
found that out of 1 1 1 cases only 6 were under
the age of ten The distinguishing feature of
it is that membranes, which the patient usually
calls skins, aie passed from the anus They
are usually white, but may be biown from ftecal
staining In extreme cases the membrane forms
a complete tubular cost of tho intestine, usually
varying from one to six inches long, but such
tubes have been known to bo much longer, and
sufficiently thin and tenacious to permit of their
being held up The wall of tho tube may be
laminated, and faeces may be found between the
laminae, showing that they have been laid down
at intervals Fiecal mattci may also be found
in the tubes, the diametei of which may be any-
thing up to H inch The thickness of the wall
may be anything up to a quarter of an inch
Either with 01 without the tubes, shreds of all
shapes and sizes uiay be passed, but in essential
characters they are the same as the tubes
Often several pieces of mcmbiano are passed
rolled up into a ball Under the microscope
tho membranes are structureless and tiansparent,
embedded in them may bo seen minute fragments
of food and faces, some cells, free nuclei, micro-
organisms, phosphates, and cholcstcim crystals
The cells are apparently the epithelial cells of
tho intestine that have undeigonc fatty de-
generation When the inner surface of the
membianc is magnified it appears reticulate, and
presents at regular intervals depressions or even
perforations that clearly correspond to Lieber-
kuhu's follicles, and sometimes it is evident that
tho cells lining tho crypts have been cast off
with them Chemically the membrane consists
180
COLON, DISEASES OP
of mucus, and is a coagulated secretion of the
intestinal mucous membrane
The patients who suffer from this disease are
usually neurotic dyspeptics of a depressed turn
of mind, and liable to attacks of constipation
They are poor caters, believing that first this
and then that article of food disagrees \\ith
them, so that their diet soon Incomes voiy re-
stricted in choice and quantity, they are usually
thin, amemic, and complain of the cold , the
tongue is pale and a little furred, the bmvels are
frequently rather constipated, and the constipa-
tion may alternate with attacks of diarrhoea
Sufferers from membranous colitis are as a rule
taciturn, they rarely have buoyant spirits ,
they take a gloomy view of life, and exaggerate
the importance of trifles. These symptoms and
this frame of mind are constantly \v ith the patient,
but there are exacerbations from time to time
during which there is much additional pain,
usually gnping, generally along the course of
the colon, and often coming on a long while after
food During these exacerbations flatulence is
troublesome, loss of appetite and constipation
are very marked , the patient may complain of
nausea or suffer fiom actual vomiting, the
tongue is very furred and may be red, and the
mental depression and feeling of weariness are
very pronounced After this state of things has
gone on for a week, the patient notices that bhe
has passed a considerable quantity of " skins "
In a mild case the patient is in the intervals
between these attacks restoied to feeble health
without the passage of any membrane, but in
other cases some but less membrane is passed
in between these exacerbations of the disease
When passing membranes the patient is as a
rule excessively constipated, and frequently takes
enormous quantities of purgatives The act of
defalcation is often excessively painful I have
known a patient Hit on the \\atei-closct for a
couple of hours suffering from agonising gupmg
pain before a motion, consisting of enough blood
and membranes to fill a half-pint measure, was
passed This patient often had to take a
morphia injection dining defecation, and t \\ice
she fainted in the water-closet As a rule a
rectal examination ic veals nothing abnormal
Only in mild cases does the opening of the
bowels relievo the symptoms fiorn which the
patient suffers
Women who complain of membranous colitis
are particularly prone to suffer fiom amenorrhoua
and pelvic troubles , indeed, almost every case
that consults a general physician has been pre-
viously under the care of a gynecologist Most
of these patients, if severely ill, are valetudi-
narians who drag out their lives passing from one
health resort to another, and many of them
have enteroptosis or prolapse of the intestines.
Treatment. — Between the attacks the patient
should in all respects lead as healthy a life as
possible. She should take plenty of exercise,
.tiding or playing golf is infinitely preferable to
dull solitary walks taken merely for the sake of
taking exercise The diet should be ample,
most of these patients decline first one article of
food and then another, until at last they are
not only underfed, but their digestive powers
are overtaxed in one particular direction An
obviously indigestible dietary should be avoided,
but otherwise the patient should partake of
whatever is put before her It should be well
cooked, and the meals must be as tempting as
possible , they should be at regular times. Van
Noordcn thinks that there should be plenty of
coarse vegetables and fruit so as to mechanically
act upon the colon. The patient should go to
bed early, and have eight hours' sleep All
these patients are worse if they are idle , they
should always have some occupation Purga-
tives should be avoided, for they are particulaily
liable to cause indigestion , the bowels should
be kept open by going to the water-closet regu-
larly at the same time every day, by healthy
living, and if necessary by a little abdominal
massage before rising in the morning A holiday
and change of scene to some such bracing place
as Switzerland or Norway is often of the greatest
benefit Indeed, these patients derive much
benefit from such a holiday even when they are
not passing membranes. Dunng the peuod
when they are passed it is particularly important
not to give purgatives by the mouth , but if the
constipation be extreme and the gnping pain
severe, considerable relief may be afforded by a
rectal injection of a drachm of glycerine or half
a pint of warm oil or soap and watci For a
severe case rest m bed, moiphia injected subcuta-
neously, and the application of hot fomentations
to the abdomen, may be necessaiy , but opiates
should not be piescribed unless they aie abso-
lutely necessaiy, for not only do they increase
the constipation, but sufferers fiom membian-
ous colitis are just the sort of people who may
have become addicted to an excessne use of
these agents
Piobably futuie experience will show that
nturai the patient has tried all other means of
relief without success, and \\hen suffering is so
great that life is a burden, that the best treat-
ment is to open the colon on the right side, and
thus give the diseased bowel complete rest
The artificial anus may then be closed 1 be-
lieve the first published case m which this treat-
ment was adopted was one brought before the
Clinical Society by Mr (2oldmg-13ird and myself
in 1895, and since then other authors have
published eases and Mr Goldmg-Bird and 1
have brought two others before the Clinical
Society The small experience we have at
present of this method of treatment appears
to show that the artificial anus should be left
open for at least six months This obviously in
many cases will prevent this treatment, for it IB
exceptional to find a colotomy plug fit so well
COLON, DISEASES OF
181
that the patient can carry on her employment
Still, the published cases are on the whole
encouraging, and one of our patients appears to
be permanently cured We have found that it
is quite unnecessary to wash out the bowel from
the artificial to the natural anus In more than
one case the formation of membrane ceased
when the bowel was attached to the colotomy
wound, even before it was opened, showing
apparently a reflex arrest of the morbid process
This quite accords with \\hat wo have said as
to the importance of the neurotic element in
membranous colitis
Recently Einhoin has adopted the following
method of treatment During the attacks he
orders rest in bed, gives borne opium , between
the attacks he injects eight to fifteen ounces of
warm olive oil into the lx>wcl e\eiy night This
the patient, if possible, retains These injections
are given nightly for three weeks, and are then
gradually reduced in frequency till one only is
given every \veek for five or six months
Secondary menibianouv colitis is not of much
clinical importance, for the maladies with which
it is associated are so severe as to mask any dis-
comfort duo to the membranous colitis As
dyspeptic membranous colitis is rarely fatal, the
phrase membranous colitis as used in the dead-
house neaily always refeis to the sccondaiy
foim , on the other hand, the phrase as used in
piactico ueaily always refers to the pi unary
f 01 m, for patients affected with the secondary
variety do not oiten pass much membrane
Direct nutation may cause secondary mem-
branous colitis, as in the cases in which it has
followed meicinml potKonin<h m which condition
it is almost ceitam that the memhianous colitis
is due to the excietion of mercury into the large
intestine It may also be sejrtic, as in the case
of a woman who died of puerperal fever, and in
whom the whole of the laige intestine was
buried by a greenish-black membrane Second-
ary membranous colitis may also be associated
with Jitujht'v disease, pneumonia, diabetes, and
MUM*, and it is said, too, with othei specific
fevois and tubeicle Fat nettosn of the peii-
toneum has been seen in cases of membranous
colitis
3 ULCKUATIVK COLITIS — The colon is fre-
quently ulcerated as a result of typhoid fe\ei,
dysentery, tubeiculosis, or malignant disease,
but from time to time we meet with cases in
which this part of the bowel is extensively
ulcerated quite apart from any of these diseases
Observation at the bedside has shown that
noaily all pitients in whom this independent
ulceiation is found after death have during life
presented such a grouping of symptoms as to
enable us to predict that the colon would
be found ulcerated To this disease, with
its characteristic symptoms and characteristic
morbid anatomy, the name simple ulceratue
colitis, or, more shortly, ulcerativo colitis, is
applied It is a bad name, because the colon is
ulcerated in other diseases , but it is so gener-
ally used that much confusion would be caused
by any alteration of it at present
The cause of this disease is unknown, but it
is probably due to a micro-organism , and possibly
different varieties of it aie caused by different
but closely allied micro-organisms It appears
to bo moie common in asylums than in ordinary
practice, but otheiwise nothing certainly is
known of its relationships except that it is often
associated with Bnght's disease, but it is said in
olden days to ha\e been associated in asylums
with typhus Statistics would seem at first
sight to show that it has been more commonly
met with of late years than formerly, but this
is probably due to the fact that we have only
recently learned to recognise it
It is not a disease of < hildhood nor oi old age,
for the patients are usually between 25 and 55
years old, it is equally common in men and
women
Symptom* — It is nearly always the state of
the bowels which seriously directs a patient's
attention to his illness The first symptom
which he remembers is usually abdominal pain,
generally griping, sometimes very sharp and
se\eie, and often sudden in its onset Soon it
disappears, only to reappear latei The duration
of these painful attacks varies from a few
minutes to many hours, and their alternate
appearance and disappoarance is \ery charactci-
istu The pain is always refeired to the front
of the abdomen, but its exact position vanes in
different cases, and also in different attacks in
the same patient Occasionally there is also
pain in the back and loins, and once I have
known a patient complain of such severe pain
in the front and the sides of the chest that she
was incorrectly thought to have pleurisy as well
<ts ulceiatne colitis In acute cases the first
attack may be excruciatingly severe, but often
it does not cause much suffering , the intensity
of the pain, howe\er, mci eases in cacii succeed-
ing attack In the interval between the attacks
the patient is usually quite free, or he may com-
plain of a dull pain in the abdomen. It should
be mentioned that the pain beais no relation-
ship to the mgestion of food, but is commonly
worse when the bowels are open The mere
presence of ulcers is insufficient to explain the
pain, for it is commonly absent in typhoid fever,
it is probably due to some peculiarly irritating
ingredient of the contents of the intestines,
which stimulates the net ves exposed on the floor
of the ulcer, and thus sets up irregular peri-
staltic contractions In the majority of cases
theio is no abdominal tenderness , when this is
present it is rarely intense, and most often it is
especially marked over some part of the colon.
The piesence of severe diarrhoea — sometimes
interrupted by short periods of constipation — is
almost of equal symptomatic importance to the
182
COLON, DISEASES OF
pain ; it is often the first symptom noticed, and
these two symptoms are never absent through-
out the whole of a case The frequency with
which the bowels are open commonly varies
between two and about a dozen times in the
twenty-four hours Although the act of defceca-
tion is often accompanied by abdominal pain,
there is rarely the intense tcnesmus character-
istic of dysentery, nor have I heard of a patient
complaining of that almost constant desire to go
to stool which is so frequent in a severe dys-
enteric attack If the cabo is mild an occasional
solid motion may bo passed, but the evacuations
are nearly always fluid, dark, foul-smelling, and
of a consistency varying between that of slime
and water So far as my experience goes, they
never resemble ordinary dysenteric or choleraic
stools , indeed I think they are bo unlike that
the distinction is probably of some diagnostic
value But it is only right to add that some of
those whose work lies chiefly in asylums regard
the ulcerative colitis they see as a variety of
dysentery Blood is commonly present, some
times in considerable quantities, so that the
patient describes the motions as being like red
currant jelly, sometimes only m traces It is
more often fluid than solid, and is usually bright
red, showing that the bleeding has been recent
Commonly it is passed with the motion, although
not intimately mixed with it The clots may
be of such a shape as to suggest that they have
recently come from the flooi of an ulcer
When diarrhoea is present very little faecal
matter is scon in the motions, and what there ib
consists of a few small lumps scattered about in
the fluid In some cases a little mucus has
been observed, but it is never present in large
quantities. Often shreddy masses looking very
like sloughs are seen, under the microscope
they are generally stiuctureless t probably their
structure has been destroyed by the action of
the contents of the large intestine
Soon other symptoms aie suporadded to the
pain and diarrhoea The most frequent of thebo,
and one of the earliest, is \omiting. Often the
patients say that they have been vomiting inces-
santly, but under careful dieting and rest in bed
this usually subsides Occasionally it is entirely
absent , it bears no relationship to the intensity
of the ulceration Thnst, probably due in part
to the vomiting and diarrhoea, may be very
troublesome Nausea, either with or without
vomiting, may be complained of The tongue is
usually covered with a dirty white fur , but as
the disease progresses, it becomes red and dry
with a brown fur If the patient be seriously
ill, his face has the drawn expression character-
istic of abdominal disease. The abdomen is
commonly distended, and peristaltic movements
may be visible A rectal examination should
never be omitted, for it may be possible to feel
the ulceration, and also to determine whether
malignant disease is present
The general symptoms are such as would
naturally be expected. The patient gradually
becomes wasted, anaemic, and excessively weak,
so that he lies in bed looking bloodless, sallow,
and extremely ill The pulse is feeble, and
hicmic murmurs may be heard. Irregular
pyroxia is often present, the temperature rang-
ing between 100° and 102°, but if the patient
be very collapsed it may be subnormal ; on the
other hand, I have known it as high as 104°.
Towards the end of the patient's life he sinks
into the typhoid state The cause of death is
usually exhaustion, and in some cases it is dis-
tinctly accelerated by haemorrhage Occasionally
perfoiation kills It is noteworthy that, although
ulcerative colitis is frequently associated with
granular kidneys, suffcreis from it do not often
show signs of imemia
Prognosis — This is very giavo — so grave,
indeed, that when patients appear to recover
from it, it is quite an open question whether the
diagnosis was correct, still, sometimes patients
with every symptom of ulceiative colitis do get
well. The patient is usually dead in eight weeks
from the commencement of the illness The
symptoms which especially indicate a speedy
termination are great tympanites, much loss of
blood, very profuse diarrhoea, and occasionally a
high temperature Some obsoiveis state that it
is the cause of death of a third of the patients in
asylums
Diagnosis — 1 think there is little doubt
that ulcerative colitis is a distinct disease from
dysentery, but the matter cannot be absolutely
settled while our knowledge of the bacteriology
of the two diseases is so imperfect Ulcerative
colitis docs not attack all ages , the bowels aie
never open 50 or 100 times a day , there is no
severe tenesmus, the motions aie not dysenteric,
vomiting is common, and Bright's disease is
often present In England the two diseases
are not likely to be confounded, for acute dys-
entery is not common, and chronic dysentery is
too long-lasting to be confounded with ulcerative
colitis In actual practice the difficulty of dia-
gnosis is usually to separate uhorative colitis
fioin malignant disease of the large intestine,
from intestinal obstruction, and from some form
of jmmary anaemia, but a mistake is usually
due rather to a faulty examination of the patient
than to any real difficulty
Morbid Anatomy — Any part of the large
intestine may be affected, and generally the
ulceration has no special distribution In an
exticme case the muscular coat is exposed, the
floor of the ulcers can be seen distinctly to con-
sist of bundles of muscular fibres, and the ulcera-
tion is so extensive that only islets of mucous
membrane are left here and there , often they
arc considerably swollen, and consequently they
look tailor than they otherwise would , and fre-
quently they are more or less stalked because of
the ulceration which undermines them The
COLON, DISEASES OF
183
result of this IB that a careless observer takes
the islets of mucous membrane for polypoid
growths, and the exposed muscular coat for the
natural level of the colon The vessels of the
mucous membrane arc dilated The numbci of
ulcers vanes from one or two to sovcial dozens ,
but while ulcers of recent date are often more or
less circular, and vary in size from a pea to a
five-shilling piece, by the time death occurs their
shape is usually very irregular, and they have
run one into another. Attempts at repair are
very rare Perforations may be very numerous
In some cases the small intestine is affected as
well as the colon, but this is rare, and the pro-
cess is much more severe and apparently of
longer standing in the colon. The liver is often
fatty
A woimted Duseattei — I have already mentioned
that the disease is common in asylums, and there
patients dying from ulcerative colitis are fre-
quently found to have pneumonia Gcmmel
thinks the onset of pneumonia always fatal
Outside asylums, chronic Bright's disease is the
condition most frequently associated with ulcera-
tivo colitis, and even in GemmeFs asylum, out
of eighty fatal cases of ulcerative colitis the
kidneys weie cirrhotic in thirty-five One of
Bright's original cases of albuminous urmc is
that of a woman aged 40, in whom the kidneys
were hard, lough, and tabulated, and the Urge
intestine was ulcerated thumghout Pycenuc
hepatic abscesses are very rare, but occasionally
a single large hepatic abscess occuis in association
with ulceicitive colitis
Treatment — Unfortunately this avails but
little The patient must lemam in bod and bo
kept warm If the pain be very seveie, hot
abdominal fomentations aie comforting The
diet should consist of milk, and often a little
brandy is required Bearing m mind the abdom-
inal pain, and that the diarrhoea is often exces-
sive, opium is piobably the best drug to prescribe
In a severe case the patient should be kept well
under its influence , it matters little what pre-
paration is given, caie of course being exercised
if the patient has chronic Bright's disease Half
or three-quarteis of a pint of a satin ated solu-
tion of boracic acid at about 100° F may twice
a day be let to run slowly into the bowel through
a long rectal tube introduced as far as possible
while the hips are raised Gemmel uses salol
dissolved in turpentine in the same way, and he
attaches much importance to the administration
of quinine by the mouth The administration of
01 eucalyptus, in capsule form (m v 1 1 d ), has
been found of service, and deserves a further
trial Perhaps m suitable cases it would be a
good thing to open the colon on the right side,
to let the faeces be discharged through the arti-
ficial anus, and then to syringe through from it
with some antiseptic solution
OTHER VARIETIES — FoUmtlar ulceration is of
very little clinical importance, so it need not
detain us long It begins by an accumulation of
small round cells m the solitary follicles, which
therefore swell, later they rupture and the
ulcers are formed These ulcers do not extend
deeply , they have sharply cut edges, and in a
well-marked example the gut is quite honey-
combed with them, vaiymg in sue fiom a hemp-
seed to a laige pea I havo^never met with any
case m which there was an attempt at repair,
nor, on the other hand, have I ever heard of
perforation, for the floor of the ulcer is always
foimed by the muscular coat.
The patients m whom follicular ulceration is
found have always died of some other disease,
often of the gastto-mtcstinal tract Thus I find
that of ten adults, one had dysentery, one cancer
of the rectum, one membranous colitis, one
typhoid fever, and one femoral hernia Follicu-
lar ulceration of the colon occurs about once
in every 500 post-mortems in hospital practice.
It is never diagnosed during life, ior the symp-
toms of the fatal disease quite overshadow any
that might be attributable to the ulceration
It is proportionately more frequent in children
than in adults Thus Holt met with follicular
ulceis in the intestine in twenty out of seventy
fatal cases of infantile non-tuberculous diarrhoea
They \\eie never seen in cases that had lasted
less than a week, and the proportion of follicular
ulceration was highest in those that had lasted
more than ten weeks When in the small intes-
tine they were always most numerous near the
Ctccum
Vascular tdteratwn of the colon is chiefly of
pathological interest There are two varieties
of it — \enous and aiterial The venous form is
by no means uncommon, and is piobably due to
the same cause as venous ulceration elsewhere
The arterial is due eithci to blocking of one of
the mesentenc arteries by an embolus, to arterial
thrombosis, or to atheioma, especially that of
the aorta just at the ongm of the mesonteric
arteries None of these are sufficiently common
to call for notice here
Jlcenun i haqtc Ulcadtion — In some diseases
submucous extravasations of blood take place
into the colon, and these no doubt may break
down and lead to ulceiation Ileemoirhagic
ulcers arc usually small, shallow, rounded, and
discrete, although occasionally two or three may
run togethei , submucous hcemorrhagcs may
commonly be seen in their neighbourhood
Hacmorrhagic ulcers are by no means uncommon
in those who ha\o had Bright's disease This is
what might be expected, for we know that
persons with Bright's disease arc particularly
liable to haemorrhage from any part of the body
They may occur too in other diseases, such as
purpura, scurvy, and other forms of anaemia.
Tiophic Ulceiation — It is by no means proved
that the intestine is ever ulcerated as a result of
lesions of the central nervous system, but several
cases have been put upon record — and quite
184
COLON, DISEASES OF
recently I have seen one not yet recorded — in
which intestinal ulceration was associated with
disease of the spinal cord. The following is an
instance : A man had complete paraplegia as a
result of a fracture of the spine in the lumbar
region. There were numerous small round
ulcers occupying the whole of the colon Many
more cases will have to be observed before the
question of trophic intestinal ulceration can bo
settled, but as a lesion of the spinal cord can
lead to an ulcer of the lower extremities, it is
not unlikely that it might lead to an ulceration
of the intestine.
DILATATION OP THE COLON — Cases m which
the large intestine is dilated may be divided into
four groups.
The first contains those in which the dis-
tension is entirely gaseous, is not duo to any
obstruction, and is only ono symptom of some
other illness It is often seen in association
with peritonitis and typhoid fever, and may
occur in almost any severe illness When ex-
treme it is of great importance, for it adds con-
siderably to the danger of the original disease,
and greatly hampers the movement of the heart
and lungs The abdomen is very distended and
tense, it hardly moves on respiration, it us hyper-
resonant on percussion, and the tympamtic note
extends well into the flanks, the liver is pushed
up and the splenic dulness is obliterated, the
patients are nearly always constipated and do
not pass much flatus per rectum, but they com-
plain of borborygmi which may be audible to
bystanders The gas consists chiefly of carbonic
acid and hydrogen The only difficulty of dia-
gnosis likely to occur is m the distinction of this
condition from those rare cases in which there is
gas in the peritoneal cavity
The treatment of tympanites is very difficult
and uncertain Various carminatives, especially
the aromatic oils, are often recommended, but
although I have often given them I have never
seen them to be of any use in serious gaseous
distension of the large intestine Enemas give
a better chance of success , those of osafootida
and turpentine aie the most useful, but vvo
naturally shrink from the use of large onemata
in typhoid fever or peritonitis Puncture of the
towel has been recommended It should bo
done with a sterilised tiocar and cannula, but it
often fails to give relief, for the gas soon collects
again Acupuncture should never be employed,
for it often leads to an escape of gas into the
peritoneal cavity
The second group contains those cases in which
dilatation of the colon is due to some solid sub-
stance within it Concretions consisting of vege-
table fibres, hair, and other foreign bodies are
sometimes found in the insane A gall-stone
may rarely block the colon, but m the immense
majority of cases in ^hich it causes intestinal
obstruction it stops m the lower part of the
Ileum. Distension of the large intestine by
faecal matter is of great importance, and f weal
impaction is a common cause of intestinal ob-
struction, under which heading it will be found
described.
The third group contains those cases in which
the dilatation of the colon is due to some organic
obstruction in front of the dilated duct. The
muscular coat of the dilated gut usually undci-
goes hypertrophy The intestinal contents re-
tained l>ehmd the obstruction set up some colitis,
which may proceed to ulceration, and so the \vell-
knovtu distension ulcers aie produced These
may be very numerous Foi example, ono case
is described thus "The whole of the colon
above the stncturo was distended and worm-
eaten by small ulcers" Sometimes this leads
to peiforation and consequent peritonitis It is
cunous that occasionally the ulceis may be a
long way behind the obstruction This colitis
may be difficult to treat after the obstruction
has been overcome The dilatation behind an
ol»truction may bo voiy great and load to much
abdominal distension IJy (.ireful watching of
the peristaltic movements, by percussion, and
by palpation wo can often imik« out \vhcther it
is large or small intestine that is dilated, but it
must not bo forgotten that a distended large
intestine may be bent down towards the pube*
like small intestine, or a distended small intestine
may be as largo as a normal large intestine
The fourth group contama those very rare
coses of so-called idiopathic dilatation of the
colon A few cases which have been recoided
as examples of this condition arc really instances
of faecal impoction loading to great dilatation of
the colon behind the impacted mass Putting
aside these caseH, a well-defined group exists
among those of idiopathic dilatation of ttte colon,
and the characteristic of this group is that the
dilatation is of the sigmoid flexure It may be
enormous, falling nearly thn % hole abdomen, dis-
placing the liver upwauls, and lesemblmg cither
an enormously dilated stomach, 01 so bent on
itsolf as to form two huge sacs lying vertically
side by side in the abdomen It may measure
two foot in circurafeience When the dilatation
is not of the sigmoid flexure it is usually near it
It has been suggested that the dilatation 111 all
these coses is due to kinking, set up by the
presence of impacted faeces, but this suggestion
is probably not correct, for many ot these patients
do not give a history of constipation , frecal im-
paction is very common, but the condition under
discussion is excessively raie, and, lastly, often
at the autopsy the distended bowel was not full
of faces Probably idiojtathic dilatation, of the
colon is allied to those cases of dilated stomach
in which there is no obstruction at the pylorus,
and this is especially likely to be true of those
cases in which the dilatation is confined to the
sigmoid flexure.
The symptoms of idiopathic dilatation of the
colon can be very briefly described , the condition
COLON, DISEASES OF
185
is much commoner in males than in few' 1
sometimes occurs in young children, having in
them probably existed since birth The dis-
tension of the intestine IB very great, and per-
cussion shows that it is chiefly due to gas
Shortness of breath is a cause of complaint, and
the patient may be livid because the diaphragm
is pushed up and the breathing hampered The
upward displacement of the heart gives rise to
palpitation The splenic duluess is obliterated,
the hepatic dulness is diminished, and the livct
cannot be felt The alxlomcn is always dis
tended, sometimes enormously so, and then it
may be tvmpamtic all over, usually neither
coils nor peiistaltic ino\ements die visible In
very rare eases the pressure has been so great as
to lead to uxlemn of the legs, scrotum, and penis,
and to ulbummunu Most of the patients foi
some tune, often for yearn, have had some diffi-
culty with the bowels, constipation supervening
from time to time , but this is not usually very
serious, and hat* yielded to purgatn cs or enemas
After death, both layers of the musculai coat
are found to be hypertrophicd, and there is often
some ulceiation of the dilated mucous membrane
The distended bowel contains Home serin -sol id
faeces and an enoimous quantity of g.is Of the
lecorded cases all the patients except one ha\e
died occasionally death IH duo to perforation of
an ulcer, but more frequently the cause of it IH
by no means clear, and then it may be sudden
The treatment has hitherto been very unsatis-
factoiy Probably the best course would be to
open the bowel above the dilatation, wash out
the dilated part, and let the f jjces pass for some
time thiough the artificial anus, and so give the
affected part rest
SACCUT ATION OK TUB COLON is not a common
condition The diverticula are usually the si/e
of a pea, but they may be large enough to rccene
the little finger, and half an inch in depth
They are most frequent m the descending colon,
siguioid flexure, or upper part of the rectum
Usually they are very numerous, are placed close
together, and contain a little faecal matter They
are to bo icgarded aw heimal piotrusions of the
mucous membrane thiough the muscular coat
They are found for the most pait m elderly
people Only once have I heard of their giving
rise to symptoms, and that was in a case in
which the perforation of one of these sacculi
led to the formation of an abscess between the
left kidney, spleen, and ascending colon
INJURIES OF THR COLON — Laceration of the
Colon — Sometimes, but vciy rarely, this is due
to an enema tube or bougie, but it is not very
infrequent for a nurse or a doctor to be ex-
cessively afraid that the administration of an
enema has led to perforation of the bowel , for
in elderly people the evacuation of the bowel by
an enema is often accompanied by much faint-
ness and oven by syncope. The pulse may
become quite small and the patient appear
Collapsed Elderly or feeble people should uevoi
be allowed to get out of bed for the evacuation
of the bowels after the administration of an
enema unless they are in the habit of using
enemata
The kinds of accident that most frequently
damage the intestine aie bemef run over, kicked
in the abdomen, or stabbed there The small
intestine is much moie oiteu affected than the
laigc (See "Abdomen, Injuries of ")
Perforation of tfa Colon ftom without — All
sorts oi abscesses may burst into the colon , thus
iliac and psoas abscesses, local ised peritoneal
collections of pus he]>atic abscesses, appcndicular
tibscesses, splenic abscesses, ovarian abscesses,
suppurating growths, abscesses of the gall-
W,*dder, and hydatuls of the livei may all burst
into the tolon This \ent is usually recognised
by the fact that the oiignml tumour becomes
small ei, and theie is a discharge of pus by the
bowel
MALFORMATIONS o* THR COLON — These are
excessively rare, but they depend for the most
part upon malposition of the cuuenm It will be
remembered that the first position of this struc-
ture is outside the abdomen, then inside just
under the. umbilicus, then to the lower pait of
the left side of the abdomen, next near the
cardiac end of the stomach, later under the liver,
and lastly in the right iliac fossa The cjecum
may remain in anj of these positions, \vhile the
colon continues to grow This naturally gives
rise to various maltoi mat ions
METALLIC PIGMENTATION OP THE COLOV —
Sometimes lead may be deposited in the tissues
ol the colon Thus a man who had lead colic
died from chronic Bright's disease The whole
of the caecum ami huge intestine was veiy black
The colon contained 0086 per cent of lead In
this case as in others the pigmentation at the
cojcum began very abruptly There IH nothing
to show that lead is not deposited m the colon
by the same process as leads to the formation of
a blue line on the gums
In very rare instances meicury and bismuth
may cause black pigmentation of the colon
MALIGNANT DISEASE OF THE COLON — A prim-
ary growth in the colon is almost always a
cylindrical celled epithclioma , it is usually
circumscnbed to a small spot, and then by
its contraction sets up intestinal obstruction.
Occasionally, however, the growth is soft and
mcdullaiy, then it breaks down m the centre,
and intestinal obstruction does not arise Thus
there are clinically two groups of cases of malig-
nant disease of the colon- those \vithout and
those with symptoms of intestinal obstruction
A post-mortem examination on the group of
cases in which there is no intestinal obstruction
reveals that several inches of colon are affected
with growth, usually foimmg an obvious tumour
visible directly the abdomen is opened. On
cutting into this mass it is found that the
186
COLON, DISEASES OF
normal channel of tho intestine is replaced by
an elongated cavity with black, ragged, sloughy
walls, but passing into healthy colon above and
below. I have known the whole of the trans-
verse colon to bo converted into such a mass
The contents of the cavity consist of a foul
mixture of faeces, blood, and neciotic growth
If the sigmoid or ceecuin is affected this mabs
may grow into the subjacent bone , if it is in
other parts of the colon, it may extend into tho
stomach, hvei, or kidneys This state of things
during life may give rise to no symptoms , on
the other hand it may bo easy during life to
detect a tumour, especially if it is in the trans-
verse colon or the caecum The patient may
pass large quantities of foul, dark grey, or black
fluid motions, m which, perhaps, fragments of
growth and small blood-clots are seen Some-
times between tho passage of such motions the
bowels may be constipated. Tho patient suffers
pain, he wastes, and may even die before any
secondary deposits show themselves When the
tumour is in the tcerum or ifu xiynioul, it may
cause oedema of one leg and thrombosis of the
external iliac vein, and when it is in tho trans-
verse colon, we must carefully distinguish n
from an enlarged liver, carcinoma of the groatei
curvature of the stomach, or an oinentum
puckered up by some form of chronic periton-
itis The implication of other organs by direct
spread of the growth rarely gives use to any
symptoms by which it can be recognised In
very rare cases of caicmoma of the large intes-
tine a nstulous tract is formed, which opens
either into the stomach, the duodenum, or some
adjacent coil of small intestine In rare instances
the carcinomatous gro\v th ulcerates directly into
the peritoneal cavity
We no\\ pass on to the description of tho
second group of cases of malignant disease of
tho colon, namely, those in which the growth
produces obstruction This variety of growth is
usually limited to a quite small portion of the
bowel, and forms an annular band, encircling
the whole circumfcicnce of the affected part of
intestine The gut from the outside appears
suddenly constricted, as though some one had
drawn a tight string around it The stricture
is therefore quite narrow, and the peritoneal
covering of the gut is usually thickened just
over the stricture From the inside the stricture
appears as an annulai and contracted deposit,
the surface of which is irregularly ulceiated
The stricture may be extremely narrow, so that
often the wonder is that the patient has pre-
sented so few symptoms The effects that occur
behind the stricture of tho bowel have already
lx?eu described , they are dilatation with hyper-
trophy of the colon and distension ulcers The
presence of these makes life hazardous I re-
member a cose m which a surgeon was to ha\e
operated on a patient one evening, but the opera-
tion was put oft until the next morning, and m the
night tho patient died from perforation of a dis-
tension ulcer On tho other hand, in very rare
cases tho opening of a distension ulcer into some
adjacent viscus, eg the bladder, has relieved
the symptoms of obstruction, or an abscess may
form aiound the distension ulcer , this abscess
bursts externally, and thus a fecal fistula is
formed
With regard to tho locality of stricture of the
colon, Troves gives the following table of 100
Sigmoid flexure
Descending colon
Splenic flexure
Transverse colon
Hepatic flexuic
Ascending colon
Ciecnm
58
11
7
7
9
2
6
100
The vymptomv of malignant stricture of tho
largo intestine are a& follow — The patient, ^ho
is usually a man of over fifty, says that for Rome
time past ho has been losing flesh, and that he
has been liable to attacks of alxlonnnal pain, not
always severe, and, to begin with, only coming
on at long intervals The attacks get moro
and more frequent, and gradually there may bo
constant pain with exacerbations. Concurrent
with these symptoms difficulty of keeping tho
bowels regular appears There are attacks of
constipation which are at first easily relieved by
aperients, but as time goes on the patient has
to take more and more apenents, until at last
he comes to a doctoi because nothing that he
takes will unlock the bowels, and then he begins
to suffer from abdominal distension, nausea, with
sometimes actual vomiting, loss of appetite, and
furred tongue But this by no means completes
the picture, foi one of the most stiikmg things
about malignant disease of tho large bowel is
that these attacks of constipation often alternate
with attacks of diarrhoea This is due to the
fact that tho retention of fueces above the
stnctuie sets up a colitis Thus it follows that
irregularity of tho bowels is one of the striking
features of this disease The motions are often
very characteristic Thus when solid they may
be altered m shape and also of small circum-
ference, owing to having passed through the
stricture, occasionally the patient describes
them as tape-like or pipe-like Too much stress
IH, however, usually laid upon the shape of the
motions, for it must be remembered that their
shape is for the most part acquired m the
rectum But when diarrhoea is present, the
motions are commonly foul -smelling, contain
mucus and, it may be, nccrotic fragments of
growth Whether there is constipation or
whether diarrhoea is present, blood is often seen
m the motions. The rectum is often stated to
be ballooned, that is to say, when the finger is
COLON, DISEASES OF
187
introduced through the anus, the rectum is
found to be empty, and so dilated that the
finger can scarcely reach the walls, which arc
perfectly smooth The cause of this condition
is quite unknown , it is not always present in
malignant disease of the colon, and it may bo
met with in other conditions The abdomen is
often very distended, and visible coils of intes-
tine may be seen conti acting thiough the
abdominal panetes These are often more
easily visible the longer the case, for hyper-
trophy of the muscular coat of the distended
bowel renders them especially conspicuous , but
it is by no means necessary that the bowels
should be hypertrophied for them to be visible,
for T have seen them \vell marked when obstruc-
tion had only existed twenty-four hours Some-
times a tumour can be felt through the abdominal
panetes This is more often ftccal accumulation
than growth If the growth extends low down
enough it may be possible to feel it per rectum,
and it may be that attention is directed to the
fact that the bowel cannot hold a copious enema
Frequent rumbling and gurgling signs are heard
in the abdomen In the gioup of cases now
being dcsciibcd, intestinal obstruction occuis
sooner or latei, and it is important to rcmembei
that even in a chrome condition, such as malig-
nant disease of the colon, the signs of intestinal
obstruction may come on acutely, and as, furthoi,
the signs of malignant disease of the colon may
be unobtrusive until acute obstruction eets in,
serious mistakes in diagnosis are by no means
uncommonly made Thus I have seen a case
which was really one of acute intestinal obstruc-
tion duo to malignant disease of the colon < ailed
acute peritonitis , but as a rule the intestinal
obstruction is chronic, and the patients give a
clear history of malignant disease of the colon
Sarcomata and innocent turnouts of the colon
aie too raie to call for mention here
Colonisation.— The tieatment of the
insane by their collection together in a village
under superintendence but without confine-
ment, the family or cottage system of pro-
vision for the insane , such a colony exists at
(Jhecl
ColOpOXla.— The flung of the sigmoid
flexure by sutures to the abdominal wall , if this
part of the colon has been incised before the
suturing, the operation is called colopexotomy
ColOptOSlS. — Downward displacement of
the colon See ENTEROPTOSIS
Colorado. See THERAPEUTICS, HEALTH
RESORTS (American)
Colorimeter.— An apparatus for deter-
mining the quantity or intensity of colour in
anything, e g. in the blood tiee BLOOD (Estima-
tion of Haemoglobin, Jfoppe-Seyler'a Colortmetttc
Met/tod).
COlOStOmy.— An operation by which a
permanent opening (to serve as an artificial
anus) is made into the colon , in colo eohstomy
two paits of the colon arc connected together
by making an opening
Colostrum. —The first milk that comes
from the mammary glands a/ter the birth of the
child , the " beestings " or " green milk " Colo*-
f ration is a disease of new-bora infants supposed
to be due to the colostium See INFANT FEED-
ING (Human Ahlk, Colostrum) , PUEHPERIUM,
PmmoLOGY (Lactation)
Colotomy.
INDICATIONS FOR 187
VARIETIES OF 188
OPERATIONS 188
(a) Left Inyuinal Colotomy 188
(6) Right Inf/uinal Colofotny 189
(c) Lvmbar Colotomy 189
(d) Tranweise Colotomy 189
A* TER-TllEAl M EN 1 190
See a/so COLON, DISEASES OF, COLOSIOMY,
INTESTINES, SURGICAL AI-FECIIONS OF, etc
THE operation of colotomy, or the formation
of an artificial anus, is undertaken for certain
grave maladies of the rectum and of other parts
of the laige intestine, and the modes of execut-
ing the operation, and the place at which it is
to be pci formed, depend themselves on the
nature and the degree of gravity of the ailment.
Formerly colotomy was regarded as an opera-
tion to be postponed until obstruction was
complete, now it is more generally used, it
should not, however, be employed without due
consideration
INDICATIONS *OR — (1ancer of the rectum and
of other poi tions of the large intestine, and
»ttictvre» and ulceiation, whether tuberculous,
syphilitic, or dysenteric, etc, sometimes com-
bined Mith extensive Jtttuto, are the main dis-
eases that call for colotomy, provided that in-
testinal anastomosis 01 resection of the stricture
is found to be impossible The chief condi-
tions, besides obstruction, which may necessitate
colotomy, aie great pun, severe Jwmotihage,
and intense and persistent diarrhoea
When the growth or stnctuie causing the
obsti action is within the rectum its exact
position can bo felt, and the surgeon can deter-
mine whether to adopt other means or to resort
to colotomy, but when the obstruction is m
any other portion of the large intestine, unless
a growth can be definitely discovcied, it is wise
to make an abdominal exploration, so as to find
out the position of the obstruction and the best
mode of dealing with it
In some forms of cancer of the rectum and
other forms of ulceration the great pain caused
by ftcces passing over the growth or into fistuln
about the buttocks of itself necessitates colo-
tomy
188
COLOTOMY
The severe and dangerous haemorrhage caused
by the passage of faces over very vascular
growths may sometimes demand colotomy
Golotomy is frequently required for persistent
diarrhoea arising from cancer of the lower part
of the sigmoid flexure and of the upper part of
the rectum, or from syphilitic or tuberculous
ulceration, not only of the lower, but also of
the upper parts of the large intestine In such
liberations, tuberculous, syphilitic, or dysen-
teric, colotomy, performed above the diseased
portion of the gut, will stay the diarrhoea
Colotomy falls under thiee heads, namely,
inguinal colotomy ; left or right, Inmlxn colotomy t
left or right, und tiaiwww colotomy The left
inguinal and the left lumbar operations are far
the most frequent, and a general preference
may ho given to the formct The opening
being in front in inguinal colotomy, it can be
attended to by the patient much more easily
than is the case in the lumbar region, and a
pad or tiuss can be more readily adjusted
The importance and possibility of being able to
procure a good spur, and so preventing faces
from passing bclo\s the colotomy opening, are
strong points in favour of the inguinal method
Especially is thin the case if the colotomy has
been done for the relief of pain, haemorrhage, or
diarrhoea
Again, a spur can always be made in the
inguinal region, but this is not so in the lumbar
region, as often the gut is too firmly fixed to
the loin, and at too groat a depth from the
surface wound
For transverse, right lumbar, and right
inguinal colotomy the rule is to perform the
colotomy immediately above the stnctuie, or
stricture with ulceration, if such be clearly
indicated In uncertain cases a median ab-
dominal exploration should first be made, and
when the seat of the obstruction la found, the
colotomy should bo done above that , thus for
disease about the splenic flexure of the colon,
transverse colotomy is the best , for disease at
or extending up to the hepatic flexure, right
lumbar colotomy is pieforable, for disease
lower down, right inguinal colotomy should be
chosen If the exploratory operation has not
had definite results, tight inguinal colotomy is
the best, so that tho surgeon may work well
altove tho diseased part of the large intestine
OPERATIONS
(a) Left Inguinal Colotomy — In left inguinal
colotomy, about an inch and a half inside the
left anterior superior spine of the ilium, and
parallel with Poupart's ligament, the skm and
cellular tissue aie divided by an incision not
more than two inches in length, and often less
The muscles are divided down to the subscrous
areolar tissue, which m torn through, the peri-
toneum is opened, the finger is introduced into
the opening, and the deep structures are
divided with scissors up to the extent of the
skin wound
My former practice was to stitch the parietal
pezitonoum to the skm, now 1 think it wiser
not to do this, as it was shown by tho late
Dr Grcig Smith that a much better union is
obtained when tho peritoneum covering tho gut
unites to muscles and cellular tissue than when
peritoneum becomes united to peritoneum
The gut is sought for and brought to the
surface, and is at once lecogmsed to be large
intestine by its longitudinal banda and appen-
dices epiploicffi While it is hold out of the
wound the mesenteiy fixing it to tho back of
the abdomen is sought for Then through the
mesentery, just as it joins the gut, a pair of
Spencer Wells's forceps (closed) arc passed, and
these forceps, pcrfoiating tho mesentery, aic
allowed to rest across the wound in the ab-
dominal wall They thus support tho gut, and
prevent it from slipping back again into the
alxlomcn The handle of the forceps should
point toward the middle line , the apex or
point of tho forceps should point outwards
A suture is then passed through the serous*
and muscular coats of the bowel, and through
the skin at the upper and lower angle of the
skin wound If necessary, thiec or four othei
sutuics may be used in like manner to unite the
gut to the skm about othci parts of the wound
I now use forceps rather than a gloss rod or
the mesentenc stitch, as they arc not so likely
to slip out, as may happen when the glass rod
is used, or tear through prematurely, as is at
times tho case with the mesentenc stitch
It is most impoibunt that these foiccps should
be kept thiough the mesentery behind the gut for
at least ten days, after which they aie removed
In from twenty-four houis to three da^s after
tho operation, the gut is opened by a transverse
incision o\er the foiceps and parallel to them
It should be m.ido only long enough so as to
allow flatus or liquid faeces to pass out
In about ten days' time, or longer, if tho
union between the gut and tho wound does not
appear to be very strong, the entire gut is cut
through in a transverse direction, the incision
going through the opening made to let out
flatus and faces This cut is carried down to
the clip forceps through the mesentery — in fact,
it absolutely divides the gut across, and thus frees
the forceps By cutting down on to the forceps,
one can make sure that the gut is leally divided
m two, for, as previously shown, the forceps at
the original operation are passed through the
mesentery behind the gut
By the cutting of the gut transversely there is
no pain, and little or no bleeding, as tho nerves
and vessels run transveisely round the gut
Tho essential point of the opeiation is to
pre\ent faces passing below the artificial in-
guinal opening, and to effect this the gut is
fixed up by the forceps through tho mesentery
COLOTOMY
189
— in other words, a spur is procured. Unless
this is obtained there will not be an artificial
anus, but a faecal fistula, beyond which faeces
pass into the dibtal portion of the gut Thus
the faecal nutation is continued, and the opera-
tion has failed in one of itb objects But when
a proper spur is made, fauces pass through the
inguinal opening only, and cannot enter the
distal end of the intestine
(6) Right inguinal tolotomy is performed by the
same incision as on the left side, but this incision
should be lo\ver down and nearer to Ponpart's
ligament The caecum is the region to be opened
The question of a spur can never arise
In cases demanding this operation, \vhcn the
caecum is very distended, Paul's tube is of veiy
great service The peritoneal cavity is opened,
and the caecum is drawn into the wound and
incised , a small Paul's tube is at once inserted,
and the caecum tied around it To the free end
of the glass tube a drainage tube is attached to
carry the faeces a\vay to some vessel remote
trom the wound Moie stitches are used to fix
the caecum to the edge of the wound The
Paul's tube is removed in a few days, when the
caecum is well glued up to the suitacc Paul's
tube should be used in all parts of the large
intestine when distension is great and it is
necebsaiy to open the gut at once
(r) Lumber colotomy can be pei formed in
seveial ways, the direction of the imimon and
the mode of fixing up the gut being the mam
subjects of diftereiu e
The best incision foi finding the colon is one
with its centie half an inch posterior and mid-
way between the antenoi superior and postcrioi
superior spines of the ilium, and midway between
the last rib and the crest of the ilium From
this point Cdlhsen used a vertical incision, but
the length of this is limited, and it is not easy
to woik down upon the gut Moie room is
given in difficult cases by Amussat's transverse,
and Biyant's oblique incision
Half an inch behind the point described, and
with its centre over the chosen spot, an incision
(either transveise or oblique) H made, not longci
than two inches, for otherwise the gut may be
missed The skin and cellular tissue are divided,
and the muscles exposed and quickly divided
till the fascia lumborum is i cached This is
opened, and the quadratus lumborum is exposed
at its anterior edge The edges of the wound
are retracted, and the fat around the kidney
and the fascia lumborum is opened up Then
the gut will bulge into the wound, if it is dis-
tended and has no mesentery In straightforw ard
cases it will be recognised to be the colon by its
being uncovered by the peritoneum , for if the
peritoneum is opened, peritoneum will be seen
surrounding the gut, and the longitudinal bands,
and the appendices with these, will also be visible
The colon is then brought to the surface, and
stitched all round to the skin wound with intei-
rupted sutures, which should pierce the muscular
coat only, and not perforate the gut
But rarely is this actual presence of the colon
made absolutely certain without opening the
peritoneum, and the difficulties anse from the
position of the intestine in relation to its peri-
toneal covering and length of mesentery In
what was formeily, but erroneously, supposed
to l>e the general position, the peritoneum covers
only half or two-thirds of the circumference of
the gut, leaving the posterior pait uncovered,
with the intestine bound down to the loin If no
longitudinal band is seen, there is a danger of
opening the small intestine, or even the stomach,
imagining that the large intestine is being dealt
with I am therefore strongly of opinion that
one should intentionally make a small incision
in the peritoneum towards the inner part of the
wound, and, by finding intestine with longi-
tudinal hands or appendices epiploicac, become
certain that the large intestine has been reached.
In a second condition, where the colon IB
entirely surrounded by peiitoneum and has a
mesentery, it cannot be reached, nor can the
longitudinal bands be seen, without first open-
ing the pentoneal cavity By the index finger
inserted into the pciitonual cavity the gut can
bo felt and hooked up and sutured, as above
described, into the loin wound
In a third condition the mesentery is very
long, and the intestine may alter its position in
the abdomen so as to be on the side opposite to
that in which the incibion IH made Prior in-
vestigations failing, the external wound, and the
peritoneum to a cones-ponding extent, must be
enlarged so as to admit the hand, and a search*
is made fur the splenic 01 ior the hepatic flexure
of the colon From one of these points the colon
can bo tound, and brought to and fixed to the
skin wound
Right lumbar colotomy w performed in the
same way and with the same difficulties, as the
mesentery is usually fanly long, and therefore
it is most important to open the parietal peri-
toneum to make sure that the large intestine is
being dealt with
(d) In the infrequent operation of hantvetxe
colotomy tho rectus muscle just above the um-
bilicus IH exposed and the posterior part of its
sheath incised, and the peritoneum is picked up
and divided, and then, as in inguinal colotomy,
the large intestine must be found and recognised
by its longitudinal bands, and then pulled for-
ward and nvod outside tho al>domen The gut
is secuied to the skin by sutuies through the
peritoneal and musculai coats The incision
should always be large enough to admit tho
mtiodnction of the hand into the abdomen, to
make sure that the colotomy is being done above
the ulceration or stricture Then the lower
part of the wound is brought together as m
abdominal section, tho upper two inches are
treated as in inguinal colotomy, and through
190
COLOTOMY
them the transverse colon is brought and fixed
When a spur is required to prevent faeces passing
beyond the opening, a clip can be put behind
the gut as in the inguinal operation
AFTER-TREATMENT — For all the forms of colo-
tomy the after-treatment, mutatis mutandis, is
the same After the operation the patient is
put back to bed, lying on the back, with the
head low and a pillow placed between the knees
The use of opiates IH dissuaded, unle&s necessi-
tated by very great pain, restlessness, 01 severe
purging. For the first twenty -four hours as
little food as possible is given, the preference
being for nutrient euemata, when possible, or
soda and milk, weak tea for washing out the
mouth, and brandy and water in rare cases of
famtnesb
Several points should be noticed on the first
visit on the evening aftei the operation Pain
in the back may be remedied by turning the
patient on the side opposite to that on \t hich
the colotomy has been performed, not on the
same side Any probable bronchitis may be
prevented by the patient be propped up in bed
If wind causes much distension or tympanitis,
the bandages should be loosened , or, if neces-
sary, the dressings may be removed and the gut
slightly punctured with a lancet, so that flatus
may escape The question of the passage of
urine should be soon to
The next day the dressings are left undis-
turbed, and the diet is still kept meagre and
liquid, beef-teu being permissible
The second day after the operation the draw-
ings are removed, and the gut is opened by
scissors for about one or one and a half inches
in a transverse direction of the gut to allow of
the escape of wind or fasces This may be done
earlier or deferred, according to circumstances
Any small vessels that bleed are clipped or liga-
tured , slight oozing of blood is allowed to clot,
absorbent wool is applied to the wound, and dry
gauze is used as a covering After this, diet
can be freer, fish being allowed first.
The day after the gut has been opened the
bowels should be made to act, castoi oil or
liquorice powder being administered Any im-
paction or hard fscces that block the way should
bo carefully broken up by the finger and ohvo
oil injected The wound is dressed with wool
soaked in any antiseptic Thenceforward the
bowels must be carefully kept open
In ten days' time, when the bowels have been
\\ell emptied, the gut should be cut across as
shown 111 the descuption of the inguinal opera-
tion
A little later the patient may rise from bed
and lie on a sofa, with the colotomy opening
dressed with ointment and supported by a pad
of \vool Any tendency to contraction about
the pioxmwl opening of inguinal colotomy is
corrected by the daily passage of the finger into
the upper opening, the lower one being allowed
to contract as much as possible Old feeces
lodged in the lower bowel may cause rectal
irritation Those should be disposed of by
irrigating with water into the lower of the two
orifices towards the rectum, and then from the
rectum through the lower orifice In a short
time the lower portion of the gut will contract
and become merely a passive tube
In about three weeks the patient can walk,
wearing either a truss or abdominal bandage
The bowels should be marie to act m the morn-
ing, a kidney-shaped bowl being placed undei
the colotomy opening Aftci left lumbar or
left inguinal colotomy the motions are usually
quite solid After tians verso, right lumbar, or
right inguinal colotomy, through which the
action of most of the large intestine is stopped,
the colotomy opening being so close to the small
intestine, the faces are consequently liquid, 01
semi-liquid. This after-iesult tells against the
three higher operations, and points to the ad-
visability of doing the colotomy as low down
the large intestine as is consonant with the posi-
tion of the disease
Colour - Blindness. See AMBIAOPIA
(Ifyvterual) , COIXNJR VISION (Congenital and
Aujuued Colour-Blindness), H \STEIU A (Senary
Disorder, Oculat Ancpsthesia)
Colour Vision.
PHYSIOLOGY OP NORMAL Coi OUR VISION 1 90
Phystcal Convutei ation* 190
Phyvwloqital Considerations 191
THEORIES OP COTOUR-PEROBPTION 193
Youny-llelmholtz Theoty 193
ffenny's Theory . 194
CONGENITAL COLOUR-BLINDNESS 195
Ihstoiual Consul 'eratwnv 195
Varieties of 195
Colout-Ljuoiawe 196
Influents of Heredity a ltd Hex on, 197
Prevalence of .197
ACQUIRED COLOUR-BLINDNESS 197
Vat leties and Causes of 1 97
METHODS OP TESTING 198
QiHtlitative and Quantitative 198
PRACTICAL POINTS 199
Seamen, Raihvay Men 199
See alno BRAIN, PHYSIOLOGY or (Sensory
Centres, Half- Vision Centte) , PmsiOJOu\, THE
SENSES (Vision, Colour), FHYHIOLOOY, THE
SENSES ( Vision, Colour Sensation, Coniplrmental
Colour*, etc) , SPECTROSCOPE IN MEDICINE
(Colout)
PmsioLOGY OP NORMAL COLOUR VISION — The
complex subject of " colour vision " lies on the
boideiland between the realms of Physics and
Physiology, and an intelligent appreciation of its
many problems demands an acquaintance with
both the physical and physiological sides of the
question
Physical Considerations — The vanous physi
COLOUR VISION
191
cal forces in nature which emanate directly or
indirectly from the sun are regarded by modern
physicists as the expression or outcome of undu-
lations or wave-like motions propagated in the
hypothetical all-pervading medium — the ether
These undulations vary considerably in length
and frequency, and in tho associated physical
effects which they produce upon animate and
inanimate nature
Ascending tho scale of etheieal disturbance
fiom the long waves of comparatively slow oscil-
lation to the shortest and most rapid undula-
tions, modern physicists assume the existence
(in sequence) of ethereal rays possessing electro-
magnetic, thermic, photogenic, and actinic 01
chemical properties The first and last groups
of this series appear (m the picsent state of our
knowledge) to be devoid of effect on the human
organism, or, at leaht, we do not possess any
specialised receptive sense-organ conferring on
us a conscious knowledge ot their existence
The highly specialised nci \o-endmgs of the skin
and letina, however, provide the appropriate
receptive channels for those physical stimuli
which, by some peculiar and unknown transfor-
mation therein, endow us with the faculty for
the conscious peiception of heat and light At
present we aie only concerned \\ith the photo-
genic etheieal rays, in so far as a consideration
of them is essential to the comprehension of the
physiology of normal colour vision
As alK>ve premised, the sun is the great source
of natural light in our univcise, and tho whole
of the photogenic rays thence emitted are col-
lectively appreciated by us <is the solai white
light This apparently simple light is, however,
of a composite chaiacter, ior by means of the
spectroscope it can bo analysed into several com-
ponent and f uither indivisible parts, constituting
the donned colours of the spectrum with tho
multitudinous variety of hue or colour -tone
resulting from their gradual tiansition into
each other In the light of the now universally
accepted undulatory theory, this phenomenon
of spectral colon r-dispeision depends upon the
constitution of the solar white light, which is
composed of many groups of etheieal rays coi-
rebponding to tho individual colouis, and vary-
ing in their vibiatory late and wave-length, and
accoidmgly in their refrangibihty by lefractive
media Colour, theiefoie, is the physical equi-
valent of wave -length and frequency, and in
accordance with these attributes, the related
rays produce coirespondmgly diffeient impres-
sions upon the receptive retina, which tho in-
terpretative mind appieciates as variation in
colour
It has been experimentally determined that
the range of our appreciation for photogenic
waves begins when tho ethereal vibrations
number about four hundred billions per second,
and the wave-length is about 750 /i/*1 (which is
1 The unit /* equals one-millionth of a millimetre
equivalent to the sensation of red), and con-
tinues through the series of increasing vibra-
tions (represented by orange, yellow, green, blue,
and indigo) until the rate of oscillation has in-
creased to about eight hundred billions per
second, and the wave-length has inversely
diminished to about 380 /A/A, when the sensation
of violet is produced Beyond this point their
perception as light ceases/' and they manifest
their existence by the possession of actinic or
chemical propeitics
Upon this compound character of the solar
light tho varied phenomena of colour depend
Colour is not (as \\a& formerly supposed) an
inherent quality of the objects around us, but
is a puicly subjective sensation produced in the
special perceptive brain centres of animate
creation The infinite variety of colour seen in
external objects depends upon the selective
power which such objects possess of absorbing
and quenching, in varying degrees, certain of
the component spectral colours oi the composite
light which illuminates them, and reflecting the
remainder to the perceptive sense organ
Associated with every colour sensation the
existence of ccitain distinctive attributes, known
as colour constants oi elements, can always be
distinguished These are three in number
(1) hue, (2) punty 01 tint, and (3) bughtnesa,
luminosity, or shade
Hue is synonymous with ethereal wave-
length, for upon this physical factor colour is
solely dependent
Punty or tint depends upon the absence of
\\hite light, the less this admixture tho purer
the colour
Jirigktnesi, luminosity p, or thade depends
objectively upon the energy of \ibiations of the
ether particles, and subjectively upon the
sensitiveness of out ictina to this photogenic
physical stimulus
By means of these varying chaiactcnstics or
qualities any given colour can be scientifically
denned m terms of the constant spectral colours
Physwfaytiaf Conwfaatiatu — Tho delicate
and complex neivous expansion — the retina — is
destined for the amplification and suppoit of
the ultimate toimmal elements of the optic
nci vo fibuls — the rods and cones The pheno-
mena of Puikmje's figures and the blind spot
establish tho fact that these aie the essential
visual cells, to which (thiough tho inner layers
of the retina) the photogenic ethereal waves
must first penetrate befoie visual impulses can
originate
Upon these neive terminals the ethereal im-
pulses of from four to eight hundred billions per
second — the phj sical equivalent of their respec-
tive colour-sensations — impinge As to the
subsequent modification and qualification they
undergo in the remaining retinal layers we arc
utterly ignorant, but there can be no doubt,
from the anatomy of the structure and the rola-
192
COLOUR VISION
turn of the optic tracts to the central nervous
system, that the obscure changes which take
place in the intervening retinal layers are of
great importance to vision, with its subsidiary
perceptions of light, colour, and form
It was formerly supposed that the receptive
rods and cones mechanically vibrated in unison
with the subtle ethereal undulations , but such
rapidity of vibration of organic foimed elements
is inconceivable, and this direct transference of
energy without change of form or quality would
appear to bo physically impossible Apart from
this consideration, it is (as the Committee of the
Royal Society on Colour Vision lemaiks) "dim-
cult to conceive that matter which is so com-
paratively gross us the rods and cones which me
bituatcd on the retina, can be affected by the
merely mechanical action of the vibrations of
light" It is obvious, therefore, that some
subtle transformation of energy l>etwoen ethe-
real vibrations and visual impulses must take
place, but the nature of this change is largely a
matter of conjecture In the couise of this
transformation, the occurrence of certain physi-
cal phenomena has been definitely established
Holmgren first recognised the existence of elec-
trical processes , then Boll observed the bleach-
ing of the retinal colour under the influence of
light, which Kuehne subsequently demonstrated
was the outcome of a chemical change Again,
mechanical alterations as to the distiibution of
the pigment in the retinal epithelium, and in
the shape of the visual lods and cones, have
also been observed These varied fotms of
transformation of energy are evidently inti-
mately associated with each other m the com-
plex visual act, which involves the transforma-
tion of ethereal vibiatioti into the special
nervous visual impulse
Nervous impulses in general are now con-
sidered to be the outcome of molecular change,
generated (through the medium of some obscure
chemical piocess) as the result of some form of
physical stimulus, and piopagated along a nervo-
hbre In the special nervous impulse under
consideration, the physical stimulus is peculiarly
subtle, and the direct transference of ethereal
into molecular vibrations is not feasible on
physical grounds Whatever the mode of trans-
formation of light energy into visual impulse
may be, it is, as yet, beyond the range of
tangible demonstration Here, however, the
" chemical " theory affords a particularly appli-
cable working hypothesis, adherence to which
is certainly solicited by the knowledge of the
luady decomposition of many chemical sub-
stances m the presence of light This photo-
chemical hypothesis assumes the existence of
complex unstable and therefore easily decom-
posable visual matters in or around the terminal
Msual cells, \vhich (though not necessarily pig-
mented) can absorb light, but which do not
generate visual impulses until decomposed under
its influence. When such decomposition occurs,
chemical products are formed which are believed
to excite molecular changes in the retinal
elements, which changes are transmitted hence
up the nerve as the visual impulses of light,
colour, and form. In order that the incident
light may expend its energy m provoking the
necessary intermediary chemical change, it is
essential that the photogenic waves be first
arrested and absoibed. The minute structure
of the retina demonstrates the existence of a
specially differentiated brown pigment — fuscm
— in the retinal epithelium, which may fulfil
this function The chief pigment of the visual
cells — the visual purple or rhodopsm — was,
when first disco veied in 1876, regarded as the
special visual mutter, the subject of photo-
chemical decomposition Under the influence
of solar light this is hrst changed to visual
yellow (xanthopsin), and subsequently to visual
white (leukopsm), while mono-chromatic spec-
tral colours also produce the photo-chemical
effect less rapidly in pioportion to their absorj)-
tion by the puiple. Jt was naturally believed
that the physical basis of visual impulse and
colour-sensation had been isolated , and the fact
that the visual efficiency of the rays cot respond-
ing to colour is relative to then photo-chemical
effect upon the purple, incidentally lent suppoit
to this belief The idea, however, had to be
abandoned, for visual purple is only found in
the rods, is quite absent in the cones of the
human fovea ceutrahs (\\here vision is most
acute), and may be naturally 01 artificially
absent in annuals which see well The visual
nmtteis are as yet, therefore, of puiely hypo-
thetical existence Analogy suggests that some
such sensitive matters (which are probably
colourless and ha\e therefore, so far, escaped
detection) do exist as the physical basis of visual
impulse These, by varying photo - chemical
decomposition under the influence of light of
ceitam wave-lengths, generate corresponding
impulses in the retina, which m accordance
with their particular characteristics aie appre-
ciated by the perceptive visual centres as the
relative colour-sensations
The assumption that the retina is the portion
of the visual appmatus mainly concerned m the
differentiation of normal colour-perception is,
rendered very probable, and apparently justified
by considerations which may be thus enumer-
ated —
(a) Law ofSjtectfjc Enfrqy of Nerves — Physio-
logical research supports the view that all nerve-
impulses (actually in process of transmission)
aie of identical character, whatever the nature
(motor, sensory, or special sensory) of the nerve
may be , that the effect produced by the impulse
in any given nerve depends, not upon any varia-
tion in its structure, but upon its differentiation
to a special function, implying a particular
peripheral termination on the one hand, and
COLOUR VISION
193
association with a special area of the central
nervous system on the other, that the nerve-
fibres themselves act as indifferent conductors
to the impulses which it is their normal function
to transmit , that impulses in any given nerve
only generate its own particular effect, whether
the stimulus applied be its normal physiological
one, or any other (chemical, mechanical, or
electrical) capable of exciting it. Thus, a blow
on the eye or section of the optic nerve produces
a sensation of light , in other words, these crude
mechanical stimuli can only be appreciated by
the brain as the special sensation which it is in
the habit of receiving through this channel
This phenomenon strongly suggests the prob-
ability that the chemical pioccss which initiates
the molecular change in nervous impulses is
identical m all nerves whatever the nature of
the exciting stimulus may be , while the logical
outcome of this assumption is the nun tenabihty
of those theories winch, by supposing the nerve
terminal to undergo different changes accord-
ing to the colour striking it, endow the nerve-
fibre with the faculty for transmission of a
variety of nerve-impulse, and make the brain
the differentiating organ
Donders asserts that modern physiology will
not countenance such a view, while the researches
of Goldbcheider in the demonstration of special
dermal nerve -endings for the sensory impres-
sions of touch, pam, heat, and cold strengthen,
by analogy, the assumption that the retina M
the ditferentiatoi concerned m colour-perception
In furtherance of the above physiological law,
Dr J Wallace has tncd to demonstrate a definite
relation between the length of a cone and the
colour to which it lesponds This implies an
invariable length for each cone, which Stort has
proved is not borne out by actual fact
(ft) Unioiulai Coloui-bhndness — Well-authen-
ticated cases of this peculiar congenital condition
are known to exist Its limitation to one eye
lends support to the view that the eye rathei
than the brain is at fault, indeed such cases
can only be explained on the assumption of
a defect on the peiipheral Hide of the optic
chiasma, and probably (as vision is usually of
normal acuity) in the retina itself
Professor Rutherford aptly commented to the
effect that were congenital colour-defect of cere-
bral origin, defective colour-sense on one side of
the brain would have implicated half of each
eye rather than the whole of one
The physical and physiological processes
involved in colour- perception may be sum-
marised as comprised m throe factors, which
are essential to the process —
1 An external object with its selective absoip-
tive capacity for colour.
2 Tho physical medium — the ether — trans-
mitting the photogenic vibrations — the specific
physiological nerve stimulus.
3 The receptive subject with its special sensory
apparatus, provided with its specific and highly
specialised end-organ This nervous apparatus
is of threefold constitution, comprising —
(a) The retina with its chromo-sensitive end-
organs, and
(6) The conductiny nerve-fibre* for the recep-
tion and transmission of the special physical
homologous stimulus to
(c) The ceiebral centifv, the special perceptive
visual organ
THEORIES OF COLOUR-PKBCBPTION — It is not
necessary to assume the existence in us of as
many primary colour- sensations as there are
colours in the spectrum, for it is found that in
order to produce experimentally the multi-
tudinous variety of colour therein seen, only
three primary colours are essential It is there-
fore generally assumed that our vision is tort-
chromic, i e founded on three, or the equivalent
of three, primary colom -sensations On this
assumption the two main theories of colour-
perception are founded
Yfntng-UelmJtoltz T/iewy — This hypothesis,
piopounded by Thomas Young (1807), and
subsequently elaborated by Helmholtz (1852),
affords a clear and simple explanation of most
of the complex physiological phenomena of
colour, and it is now universally accepted
among physicists It assumes the existence of
three kinds of nerve-fibres identical as to struc-
ture and conduction, but terminating m different
end-organs endowed with photo-chemical sub-
stances respectively sensitive to the three
pnmary colours — red, gieen, and blua In
every colour- sensation these three primary
colour nerve elements are stimulated, though
m varying degrees, the icsultmg colour-sensa-
tion being determined by the proportionate
amount of the three elementary sensations In
the accompanying coloured plate the relative
degree of stimulation required for each of the
spectral colouis is indicated by the height of
the colour cuives and by the depth of the
colour
Those three symptoms of nerve-fibres are
connected with three functionally different sys-
tems of cerebral ganglion cells, whose specific
energy fits them for the perception of the
associated colour-sensation The retina is thus
made the selective or differentiating organ, and
the brain the perceptive one
The minute anatomy of the retina is looked
upon as supporting this theory, for the longi-
tudinal stuation m the outer segments of the
cones is regarded as constituting them multiple
terminal end-organs. Further — the cones being
the end-organs conccnied in the perception of
colour (Max Schultze) — the acuteness of colour-
perception should be proportionate to their
numerical distribution. This presumption is
borne out by actual fact, for colour-perception
is most acute at the macula which contains only
cones, and diminishes relative to distance from
13
194
COLOUR VISION
this point, while at the periphery of the retina
it is quite absent
Many objections to this theory have been
raised It assumes the existence of a separate
nerve-fibre to each terminal element Salzer
found about three million cones in the human
retina, while there are only about one million
in the optic nerve. Although as to the fovoa
the assumption is an essential, it is not neces-
sary in the retinal periphery , indeed, Helmholtz
explained the inipeifections of peripheral vision
on the assumption that several nerve elements
in this situation have one nerve-fibre in common
A further objection — ongmally raised by
Fick and recently revived — is founded on the
fact that a small pencil of rays from a distant
star appears white, implying, according to the
theory, that the image falls on three cones
simultaneously, whereas astronomical considera-
tions as to distance show that the tiny image
cannot cover more than one cone
Tins difficulty is ingeniously explained by
Thomas and Welland, who suggest that the
imperceptibly minute ocular oscillations con-
stantly taking place in accordance with the
rhythmical mnervation of the ocular muscles,
rapidly but successively expose several cones
to the incident rays, and that these rapidly
succeeding impressions on different colour cells
are collectively appreciated by the brain as
white light
The assertion of Chui pcntier that this theory
does not explain the fact of the central retina
being less sensitive to colour than to white
light is fallacious, for it assumes that while
monochromatic light only stimulates one brain-
cell, white light excites thiee equally, so that
the sensitiveness of the retina to compound
light is proportionately increased
Other objections against this theory have
been urged, but for the present purpose they
do not require discussion
IfernH/8 Theory — This rival theory — a modi
fication of the Young- Uelmholtz — was first
propounded about twenty years ago by Hermg
of Prague It assumes the existence in the
retina of three visual substances — \vhite-black,
red-green, and yellow -blue (in each pair one
colour being complementary and also antago-
nistic to the other), corresponding to the
supposition that we possess six fundamental
sensations. As in the metabolism of living
substances generally, the existence of two phases
can be recognised — a constructive, assimilative,
or anabolic phase, and a destructive, dissimila-
tive, or katabolic phase, — so similar metabolic
changes of opposite character in the hypothetical
visual substances under the influence of light
are presumed to be the causal factors in the
determination of nervous impulses, and their
psychological expression as conscious visual
colour-sensations
Different rays of light, according to their wave-
length, affect the several visual substances dif-
ferently, provoking constructive or destructive
changes in some, while others may be left in
equilibrium, and producing a resulting colour-
sensation expressive of the balance of effect on
the whole The accompanying diagram from
Foster's Text-Book of Physiology (sixth edition,
part iv p 95) serves to indicate the nature
of Hering's assumption with regard to colour-
perception
The vertical lines R, 0, Y, G, B, V indicate
the position on the spectrum of the correspond-
ing colour whose initials they bear The curved
line ?</ (enclosing a space shaded vertically)
represents the red-green substance, the effect
of rays of different wave-length upon it being
indicated by the height of the curves The
line yb (enclosing a space shaded horizontally)
represents the yellow-blue substance, the effect
of various rays upon it being indicated in the
same manner The horizontal line ab separates
the katabolic, dissimilative, or destructive
changes (represented above the line) from the
anabolic, assimilative, or constructive changes
(shown below it). In the red-green suhstan< e,
as far as the line Y (? e for red, oiange, yellow)
the effect is katabolic, producing a red sensa-
tion , beyond this point (i e for green and blue)
the effect is anabolic, producing a green sensa-
tion In the yellow-blue substance the effect is
katabolic up to G (/ e for orange, yellow, and
green), producing the sensation of yellow , but
beyond this point (i e for blue and violet) it is
anabolic, producing the sensation of blue The
thick lino wb (enclosing an unshaded space)
indicates the \vhite-black substance which is
only affected katabohcally, though to a variable
degree, by nil the spectral colouis, producing
the sensation of white Its aiubolism produces
the sensation of darkness
Red light (R) pioduces the sensation of red
by inducing a katabolic change in the rcd-giecn
substance Orange induces katabolic changes in
both the red-green and yellow -blue substances
Yellow produces katabohsm of the yellow -
blue substance, the rod- green now being
in equilibrium (its cuivo intersecting the line
ab) Green induces anabolic changes in the
red-grcon substance, the yellow-blue now being
in equilibrium Blue produces analx)hc changes
in the yellow -blue substance, Molet also does
the same, but to a lesser degree The simul-
taneous effect of mixed lights is the sum-total
of the effect of their several component colours
Ebbmghaus has modified Horing's theory by
admitting only katabolic changes in the three
Msual substances as the cause of colour-sensa-
tion He attributes colour properties to the
visual purple, which latter he considers mdenti-
cal with the yellow-blue substance He asserts
that it exists in the cones as well as in the rods,
and that its apparent absence in the former is
due to its being colourless from admixture with
Yellow-blue Substance
White-black Substance
R O Y G B V
Rg 1. DIAGRAM ILLUSTRATING HERINQ'S THEORY OF COLOUR PERCEPTION
Green Curve
Curve
ROY G B I V
Fig. 2. BLUE-BLINDNESS ACCORDING TO THE YOUNG HELMHOLTZ THEORY.
Green Curve
R O Y G B I V
Fig. 3. GREEN-BLINDNESS ACCORDING ro ran YOUNQ HELMHOLTZ THEORY.
Red Curve.
Curve.
R O Y G B I V
Fig 4. RED-BLINDNESS ACCORDING TO THE YOUNQ-HELMHOLTZ THEORY.
mo ftu» page 19*
COLOUR VISION
195
the complementary red-green substance, which
is present only in the cones The outcome of
this assumption, viz that the nerve of any cone
transmits impulses varying according to the
colour, is, however, opposed to the views of
present-day nerve physiology
The above two theories are the only hypo-
theses relating to colour-perception which now
hold the held , and though there are still
adherents to Heimg's theory, that of Young-
Helmholtz meets with the more universal
acceptance All other theories which endow
the optic nerve-fibres with the faculty of trans-
mitting nerve-impulses of varying characteristics
are antagonistic to the accepted facts of present-
day nerve physiology
Development of Colour-peirrption — Colotir-
sense and colour-knowledge must not be con-
founded , the former is an inherited instinct,
the latter results from education and practice of
the sense
Ample evidence exists that the coloui -sense
was coexistent with primitive man of whom we
possess any trace Among the deposits found
in the sepulchral bariows of prehistoric times are
variously coloured glass or quartz beads and elab-
orately aitistic implements and pottery , \\hilo
the enamelled bricks ot Nineveh and Babylon
and the Egyptian mummy-casos show that the
ancient inhabitants of the land of the Pharaohs
possessed a colour-sense of the highest order
It is evident to any caieful observer that a
kocn appreciation of colour is one of the marked
endowments of early infancy The colour
vocabulary is absent, but education in the
nomenclature of colour is alone requuod to
voice the existence of the sense The ordinal y
vocabulary for colour is a simple one— black,
white, red, blue, green, yellow, grey, bro\vn ,
and though the majority of educated individuals
are content \vith so mcagie a list, there is no
reason why such should not be indefinitely ex-
tended Though we have no means of knowing
how certain terms were oiigmally used or applied
to designate the primary colours, the abstract
nature of coloui m the development of the colour
vocabulary is interesting Most of our colour-
names take their origin fiom some concicte
object Thus the baking of a certain kind of
clay gives us " buck-red," while another variety
of clay gives us " terra-cotta " In " rose-colour,"
" cardinal," " claret," the concrete origin of the
colour - name is still apparent " Rosy,"
"roseate," "pink," "carnation," "cherry,"
and " plum " are further examples, while stones
such as amethyst, amber, sapphire, turquoise,
topaz, and jet give us still more conclusive
evidence Probably the only difference between
concrete and abstiact colour-names is one of
time Orange, lilac, and even so recent an
addition as that of electric-blue, are fast losing
association with the objects from which the
names were originally derived
The natural colours with which civilised man
is brought into contact are comparatively few ,
the artificially produced hues are many and in-
creasing A pattern-card issued by a Lyons
silk manufacturer contains samples of two
thousand different colours, each with its more
or less appropriate name , and while this colour
vocabulary is larger than the entne vocabulary
of the majority of people^ the gradations of
colour in the solar spectium are still more
numerous The sense to perceive these is
already existent , as opportunity ofteis, an
extended colour vocabulary will result
Definition — Colour-blindness is the condition
in v\ Inch there is inability to distinguish certain
colours It may be tomjemtat or acquired The
subject may be discussed in terms eithei of the
Young-llelmholtz or Her ing's theory
CONGENITAL Coi OUR -BLINDNESS — J/tstoma/
Considerations — This congenital defect has
probably been coexistent with the human race
It was so named by Biewster The first un-
doubted ease appears to be one iccorded by
Huddait in the Philosophical Transaction* of
1777, \\hieh was subsequently commented on in
1779 by the Abbe Rosier, \\lio also rcferied to
the case of the painter (Vilarean The same
year the case of Scott \\as retried Then
followed the historic ease of Dalton, the English
chemist of atomic theory fame, who in 1794
studied his red-blindness by the spectrum, and
accurately described the condition The subject
was first systematically and theoretically studied
by Seebeck about 1836 (Jcorge Wilson of
Edinburgh (1818-1859), by his researches and
writings, stiongly advocated attention to the
piactical side ot the question, but his work did
not receive the attention it deserved The
measure of attention v\hich the subject in its
practical bearings is no\\ receiving is largely due
to the po\\eiful advocacy of Fnthiof Holuigicn,
of UpMala, in his \\oik published in 1877, and
of Dr B Joy Jeffries of Boston, \\ho wrote two
years later Yet even now, m spite of constant
and consistent agitation, much lemams to be
done, for Governments do not yet fully recog-
nise their duty m a mattei of such vital irn
portauce to life and property
Congenital coloin -bl 'indnt">* may be total or
paitial
Total or Complete Coloiir-blindneM — A</troma-
topsia — This condition is rare , it may be
unilateral (Otto Becker and von Hippel) The
spectrum appears in shades of grey thioughout,
being lightest in the position ot the yellow-
green, and darkest at eaeh end A coloured
picture appeals like a photograph or an engrav-
ing According to the Young- Helmholtz theory,
such cases are explicable on the assumption
that all the three photo-chemical substances are
alike, as is normally the case at the extreme
retinal periphery, or that the three colour-
receptive elements are paralysed Bering's
196
COLOUR VISION
theory asserts that all the chromatic substances
are absent, the white-black alone remaining
Mono-chromatoptna — This is a very rare
group akin to the above, in which the whole
spectrum appears in shades of bomo one colour —
green or blue-violet In such cases we assume
the existence of the corresponding photo -chemical
substance only
Partial Coluur-MindneM — Of this condition
there are three varieties designated (according to
the Young -Helniholtz theory) — blue -blindness,
green-blindness, and red-blindness All aie char-
acterised by the spectrum appearing dichromic,
with a neutral area of white or grey, as shown
in the accompanying diagram
Blue-blindness, violet-blindness, yellow-blue
blindness of Hermg, akyanopsia, axanthopsia —
This group is very rare, and therefore not of
practical importance The spectrum consists
only of red and gieen, with a neutral giey area
in the yellow, the blue -violet end is usually
much shortened. In typical cases only red and
green are seen perfectly (Krythrochloiopsy of
Mauthner), blue is confounded \vith green,
purple with red, orange with yellow, and violet
with yellow-giecn or giey According to Young-
Helmholtz, the blue-sensitive substance is hei<»
equal to, or has the properties of the gieen-
sensitive substance, as diagrammatically repre-
sented by the parallelism and pioxumty oi the
green and blue curves in the figure appended
From this it is evident that at Y (the point of
intersection of the curves), where m normal eyes
the sensation of yellow would bo perceived, all
the three substances would be equally stimu-
lated, and the sensation of grey in consequence
provoked
Bering's hypothesis explains the condition
by the absence of the yello\v-blue substance
U ni ocular cases have been recorded by Holm-
gren and other observers
Green- Mttut nets, Hcnng'b red-green blindness
with unshortened spectrum, achloropsia, aglau-
kopsia, xanthokyanopy of Mauthner — This w
a group of great piactical importance The
unshortened spectrum contains no gieen, but
appears to consist of two colours only, usually
called vanous shades of yellow and blue, which
colours join each other directly, or are sopatated
by a narrow neutral grey band In such ca«e«
bright-gieen is confounded with dark-red, and
a dark -green letter on a black ground is not
lecogmsed
According to Young- Helniholtz the giecn-
seiiHitivo retinal substance is here equal to 01
lias the properties of the red-sensitive matter,
as indicated in the accompanying diagram by
the close proximity of the green to the red
curve From this it is obvious that at G (the
point of intersection of the curves), where
normally green would be perceived, all the
three sensitive substances are stimulated equally,
and the sensation of grey IB brought about.
Red-blindness, Bering's red-green blindness
with shortened spectrum, auerythropsia, Dal-
tonism. — The spectrum is shortened owing to
the absence of the red end, and is composed
(as m green-blindness) of two colours — yellow
and blue. The differences are that the neutral
grey zone between the yellow and blue is now
nearer the blue end, and that the yellow begins
in the orange and not in the red as in green-
blindness In such cases light-red is confounded
with dark-green, and a daik-rcd letter on a
black ground is not recognised
The Youug-Helmholtz theory asserts that the
rod-sensitive substance is here equal to, 01 has
the properties of the green-sensitive substance.
This is indicated in the accompanying diagram
by the closely adjoining position of the red to
the green curve Here red at It is stimulated
so slightly that the sensation is baiely provoked,
while at the site of intersection of the curves,
GB, the noimal greenish -blue is pciccived as
grey, for heie all the three sensitive substances
are stimulated equally
Accoidmg to llering's theory, green and red
blindness aie varieties of red-green blindness
due to absence of the icd-gicen \imitil substance,
the difference in i espouse to tests being due to
vaiiation in coloui of the ocular media — the
crystalline lens and the macula lutea This
is hardly feasible, for lens discoloration only
occurs in senile or diseased eyes, whilst the
macular pigment, which undoubtedly docs affect
greenish-blue rays, barely influences those con-
cerned in the above difference
wnse, Dywhioniatupbia — In these cases, which
aie of frequent otcmrence, the auiteness oi
coloui -perception is reduced When objects are
sufficiently large and \vull illuminated, colours
aie recognised , but when seen under unfavour-
able conditions as to illumination, 01 mixed
with white1 or grey, the giound coloui s are less
readily detected than by the noimal eye. All
the spectral coloui s are appieciated, except that
violet cannot be distinguished from blue, 01 is
called giey 01 bro\vn Pure eolouis aie easily
lecogmsed, but when mixed, difficulty is ex-
perienced m picking out the dominant one, and
glad at ions in colour are less obvious
The acutcness of colour-peiception in persons
with noimal trichromatic vision is not invariably
the same , indeed a diffeience may be noticed
in the eyes of the same individual
These slight aberrations from the normal
condition aio probably attnbu table to a reduced
sensibility 01 an alteration in the relation of the
three photo-chemical substances, whereby they
simulate each other in properties, and manifest
their distinctive effects less potently
Colour-ignorame — This is ignoiance as to
colour nomenclature, and not inability to dis-
criminate between colours Its existence in
the adult is very doubtful, as evidenced by the
COLOUR VISION
197
fact that in spite of the institution of a special
colour-ignorance tost in the British Mercantile
Marine Regulations of 1894, no failure to pass
this test has hitherto been reported It only
occuis in boys of the lowest social strata whose
environment has led to a total neglect of educa-
tion in the naming of colouis
Influence of Heredity ami Sex on Cmujtmtal
Colom -Ithndnetu — These are important factors
in the genesis of this condition It occurs
much more ficquently in the male sex, and is
usually transmitted from grandfather to grand-
son, whilst the intermediate genet ation — both
male and female members — frequently escape
the defect altogether Several bi others may be
afflicted with the abnormality, in such cases the
detect usually assuming the same type in all
Veiy rarely transference of the defect to the
female members of a family is seen The visual
acuity is usually unimpaired Umocular cases
occui, but exclusively among men
PrfvnJetue of Ctm</emt(il Colom -MnirtnfSb —
Well-authenticated statistics of numeious ob-
servers who have collectively examined nearly
one hundicd thousand persons demonstrate t\\o
facts —
(«) Its prevalence among the male sex
(b) Its equal distubution in different nation-
alities
These im estigations show .in average of
3 59 per eent colom-blmd among males, and
only Hrt pei cent among females This rare
occunem-e in the female sex has been attubuted
to their special earlier individual education in
colour, while this d<x*s undoubtedly account for
the absence among them of colour-ignorance, it
is more piobable that then highly developed
colour-sensation is an hereditary endowment
peculiar to their sex,- -the outcome of a special
educational development which has been in
progress ior ugcs
ACQUIRED CoLouH-BuvnNEss — This is a con-
dition of defective coloui-poiception due to
pathological changes, affecting those whose
colour vision was formerly unimpaired In the
normal triehromic eve, the visual colour-fields
are physiologically limited to ceitam definite
areas, which vaiy m extent accoidmg to the
particular coloin, and are none of them co-
extensive \vith the held for foim Colour-per-
ception is peifeit only o\er a limited eccentric
area surrounding the macula Beyond this
limit, dc\iations normally occur similar to those
observed in the colour-blind throughout the
whole retina- -the diflercntiatum of green, led,
and blue being icspectively lost, as the retinal
peiiphery is approached, while at the ex ti erne
periphery is an achromatic zone capable only of
form vision
The distinctive symptomatic difference be-
tween congenital and acquired colour-blindness
is the associated failure of visual acuity for
form almost always present m the acquired
variety The defect usually annuls or abolishes
the colour-perception m a definite sequence—
the order of colour-disturbance being green, red,
and lastly blue It is more frequently dependent
upon pathological changes affecting the conduct-
ing nerve-fibres or the colour-sensitive cerebral
cells, than to a lesion of the third factor in
colour -perception, viz thfc retinal chromo-
sensitive visual cells This wtiological fact is
piobably explained by the apparently greater
icsistance to pathological processes offered by
the photo-chemical substances than by the optic
nerve-fibrils, as eMclcnccd by the observation of
Stilling, who found the colour-sense unimpaired
in various forms of retimtis and choroido-
retmitis, and by the statement of Leber that
in such retinal affections colour-blindness only
ensues when the disease lias led to secondary
atrophy of the nervc-fibie layer and of the optic
nerve
The affection assumes a variety of types as
to distubution, according to the pathological
factor upon which it depends The main
varieties and the associated causes may be thus
classified —
1 The colour defect may involve to a variable
extent the retinal circumference only, and remain
localised to these peripheral parts Form vision
is correspondingly restricted, the condition known
as "telescopic vision" resulting This condition
follows the administration of various theiapcutic
agents, such as quinine, sahcylate of soda, ergot,
and caffeine These drugs, from idiosyncrasy
or overdose, produce toxic effects, by disturbing
the vaso-motor centres and inducing a condition
of ictmal anrcmiu
2 It may pimianly involve the retinal peri-
phery, and progressively spread over the whole
retina This is the most frequent form, occur-
ring concurrently \vith optic nerve atrophy,
whethei pnmaiy and associated with general
nervous disease, or secondary and consecutive to
neuritis fiom any cause
3 The defect may be limited to the central
poition of the retina only, producing a central
colour scotoma, which may be pericentric or
paraccntiic according as it includes the fixation
|iomt or not This variety includes the so-called
toxic amhlyopias which in reality depend patho-
logically upon ictro-bulbar axial uemitis The
toxic agents picxlueing this condition arc alcohol,
tobacct), bisulphide of carbon, lodofoim, mtro-
benzol, cannabis mdica, aiscnic, lead, stiamomum
and chloral hydrate Central colour scotoma
aic also of fiequent occui rcncc in disseminated
scleiosis, and sometimes as the outcome of
toxccmia m diabetes
4 It may involve the corresponding halves
of each retina (chromatic homianopsia) as m
some r.ire cases of ceiebral hremorrhage or
emlxdism — the field for form l>eing unaffected
In ordinary hemiopia the loss of colour corre-
sponds to loss of foim
198
COLOUR VISION
5. Disturbance of normal colour-perception is
of frequent occurrence in certain functional
neuroses, as hysteria, epilepsy, and hypnotism
For a detailed account of the special colom
phenomena in these and in the above-mentioned
groups the reader is referred to the special
articles
tin/mil Colvur* — Hy uuivcnal custom, the
colours — red, green, and white — have been
adopted as signals to indicate conditions of
danger and safety When the prevalence of
colour-blindness in the male sex was duly recog-
nised, it was found that most colour-blind men
were either red-blind or groen-bhnd , and the
advisability of lepUcing the above colours by
others less readily mistaken was considered
Experiments, however, as to the luminosity of
various colouicd lights have satisfactorily proved
that the colours m usage are the best and the
only available signal lights for practical pur-
poses, for, while red transmits 10 per cent, and
green 10 to 20 per cent of the light behind it,
blue only allows 4 per cent to pass through,
while yellow under certain atmospheric condi-
tions would not bo sufficiently distinctive The
elimination of the colom -blind from positions
of vital responsibility became, therefore, a giave
necessity, and upwards of forty methods for the
detection have been devised
METHODS OF TESTING — Any method to lx?
scientific and conclusive must be based on the
principle of the mat<Jmi<i of colours, since this is
the only true appeal to the colour-sense The
nannny of colours is fallacious, for the truly
colour-blind may guess coirectly, while from
colour-ignorance or nervousness the colour-per-
fect may fail In methods involving the match-
ing of colours, coloured pigments seen by i effected
or tiansmitted light or the spectral colours may
be employed Of these the simplest and most
piactieal test is that of Holmgren
A Wool Tfit of Holnupeti — Seebeck was the
first to mention coloured worsteds, while Wilson
of Edinburgh was the first to employ them
Holmgren's method is an elaboiation of the
suggestion, fi\e finely graduatexl shades of cadi
of the following colours— rod, orange, yellow,
greenish-yellow, green, greenish-blue, blue, violet,
purple, lose, blown and giey — being employed
The tost consists m acquiring the examinee to
match from the heap of wools of \arious colours
and shades (confusion colours) placed on a white
cloth in a good light " tost skeins " of certain
definite colours These test skeins are tlnee
in numtar, and are applied in a given order
Test 1 — The examinee is given a skein of
\ery pure pale green (which should be held
apart) and told to select from the heap all the
skeins which contain any tint of that colour,
care being taken to avoid specifying the colour
of the test skein If any but green skeins be
selected by the examinee as a match, colour-
blindness is established, while a marked dis-
position to select such, though hnally not
yielded to, indicates a feeble colour - sense.
Should the examinee have a difficulty in under-
standing what is required of him, the examiner
himself may show him by selecting the required
skeins without in any way invalidating the
value of the test
To ascertain the kind and degree of the
coloui -defect two fmther tests may bo em-
ployed —
Test 2 — A rose-oolourod skein (a mixture
principally of red and blue in the proportion of
two to one) is now given to the examinee, and
he is asked to match it II he select blue and
pin pie skeins he is completely rod-blind, while
if he select the blue-green skeins he is com-
pletely green-blind
7'ett 3 — A bright-red skein is now presented
The complete red-blind selects as matches to
this, dark green and reds, and browns (i e
shades which to the normal eye appear daiker),
while the complete gi eon -blind selects light
gi eon and light hiowns (< e shades which to the
normal sense appear lighter than the test colour)
It does not always follow that the mistakes of
the coloiu-bhnd ate unaiiably those indicated
above As noi nwl colour-peiception vanes in
diffcient individuals, so in the coloui -blind
every gradation AS to kind and dcgiec of defect
exists While typical cases of either form
lespond, therefore, in a distinctive manner to
the tests employed, incomplete cases will be
indicated by deviation fiom these regular lines
Vaiious modifications of this method ha\e
been devised for facilitating the examination
and recoidmg the results, when dealing with
large bodies of men These may be biiefly
enumerated as follow — 1 Thomson's colour
stick, 2 Jeutteison's coloui disc, 3 (J A
Oliver's wool test, 4 IXioe's wool squaies, f>
Ileuss' coloui table , 6 Cohu's embroideiy
patterns , 7 Bodal's coloured cylinders , 8
Schenke's yam spools , 9 Dondeis' wool rolls
B Pif/meiit 7V«ft — (1ohn and Mauthner
advocate the use of bottles filled with diffeient
pigments in place of woisted
C The i/irumo-ltthoffta2>btc '«W« of titillmrj
consist of coloured letters on diffeiently col-
oured backgrounds, seen under reflected light
Grobsinann's nuxlihcation embodies this idea,
but the coloured slides are shown by transmitted
light
The above-mentioned methods only permit of
a quahtatuc determination of the colour-sense
To detcimme this quantitatively recourse must
be had to one of several methods devised by
Bonders, Oliver, and Bnidcnell Tarter
For a truly scientific estimation of the colour-
sense the spectral colours must be employed
Lord Kayleigh, Abnoy, Chibret, and Hirschbcrg
have devised instruments by means of which
definite spectral colours can be exposed and
matched for selection from another spectrum.
COLOUR VISION
199
PRACTICAL RRMARK& — Seamen — The practical
importance of the subject of coloui -blindness
was not recognised until 1855, when Dr George
Wilson of Edinburgh published his Rematches
on Colour-Blwulnesx, and graphically drew atten-
tion to the dangers of employing colour-blind
men in positions of trust In 1876 a railway
disaster at Arlsoy Junction, and the suggestion
that it was due to colour-blindness on the pait
of the engine-driver, excited public attention
In the following year the Boaid of Trade
established a compulsory test for those of the
Mercantile Marine applying for certificates of
master and mate The test consisted in the
naming of colours, the consequence being that
men i ejected at one time or place passed the
test successfully on another occasion The
perfunctory manner m which the Regulations
lespectmg coloui -blind men were drawn is
shown by the following facts —
1 Th.it no test was icquired of "look-outs,"
oidmary seamen, apprentices, or pilots
2 Th.it the coloui-bhnd officer received his
certificate, though it was cndoised "colour-
blind "
3 Th.it no piovision was mode for coloui -
blind office-is who might ronscientiously feel
their unhtness foi the sea life
The inefficiency of the so -tailed "colour-
blind test" led to a long con tioversy between
membeis oi the medical profession and the
Board of Tiade, resulting finally in the establish-
ment oi the1 Holingiuii Wool Tost as the official
test on September 1, 1894 The Boaid h«uc
not, howevei, yet usen to a full souse of their
icsponsibihty The pi unary object of (Jovoin-
nu'ut is to pi ovule s.iioguaids foi human lite
which individual care cannot command From
this standpoint then own lie-ports condemn
them Between 1877 and 1894, 72,894 sailois
ahe.uly holding 01 appl}ing for certificates weic
compulsonly examined 409 failed to pass in
colour In the same period, 6370 vduntauly
offered themselves for examination, and 29.J
failed to pass Since 1894, when the Holm-
gren test came into vogue, 21,720 have been
tested, with 232 failures, i educed on appeal to
215 Taking the figures of both periods to-
gether, between 1877 and 1898, 100,984 sailors
have been tested, and 917 found colour-blind
Of these 917 colour-blinds theie is not one tittle
of evidence to show that they have abandoned
the sea life , on the contiary, we know that in
spite of their defect they are allowed to continue
their calling, and do so to the menace of the
public safety The obvious deduction is that
while the Boaid of Trade completely fail to pro-
cure that measure of protection which the public
requnemcnts demand, the public on their part
have, by the adoption of fallacious Regulations,
been deluded into a state of false security The
recommendations of the Royal Society's Com-
mittee that all candidates for positions of trust
should be compulsoiily examined, and that in
judicial inquiries as to collisions the witnesses
should be examined for colour-blindness, would,
if earned out, open an era of safety which has
hitheito been unknown
Railway Men — Up to the present time there
has been no agreement among the various
i ail way companies as to tfre application of a
recognised standard colour- test The conse-
quence is that colour-blind men may still be
found in the ranks of railway employees
Recent agitation on the part ot the British
Medical Association will no doubt result finally
in the universal adoption of Holmgren's test,
supplemented if necessary by some quantita-
tive method
Colouring Matters. See L'IUSIO-
U}Q\, TISSUES (Pigment Celli) , PHYSIOLOGY,
KXCRETION (Uiine, Payments), PK.MENTS OF THE
BODY AND EXCRETA
Colp- or ColpO-. — In compound words,
ettljt- or eolpo- (from (Jr icoATros, vagina) signifies
relating to or belonging to the vagina In
addition to the woids specially referred to
below, there are rofyWyw, vaginal pain , colp-
atreiHi, vaginal atresia , coljwtavy, \agnial
dilatation, colpewyntet, vaginal dilating rubber
bag, tolpocile, vaginal hernia, coljtocytfiti*,
inflammation affecting both the bl.ulder and
the \agina, loijto-hy^tftcctomy^ \agmal hyster-
ectomy, colpn-leucoirhwa, vaginal leucorrhoea,
lutjwjitovi, \aginal prolapse , colponhejn*,
vaginal mpture, (oljwyMnmus, vaginal spasm,
loljwffqnnM*, vaginal atresia, colpovtenow,
vaginal constiiction , and tv/po*ynizwi>, vaginal
nan ow ness
Colpectomy.- -An extensno operation,
in which the \agina is excised, and its bed
colummsed , the utcius may be left behind
(Muller's opeiation) or removed as well (hystero-
colpectomy), it is employed m cases of in-
veterate piolapse in eldeily women (past the
menopause)
Col pit IS. — Inflammation of the \agma,
catarrhal, folliculai, emphysematous, mycotic,
or other Sre VAGIVA, DISORDERS o* (I'tiymitti)
ColpOCleislS. — Fiom Or KoATros, vagina,
and KA«'s, a key — is the opeiation by which
the \agma is permanently obliteiated 01 closed,
it is employed in intractable cases of vesico-
vagmal hstula oi of prolapsus uteri (in old
women) The requisites for the operation are
amesthetics, vaginal specula, a uteiinc sound, a
knife, curved needles, a needle -holder, and
sutures (silkwoim gut or catgut) The vaginal
canal is exposed, a ling of mmous membrane
is excised as high up as possible , the raw
sin faces on the anterior and posterior walls
thus produced are then brought together with
silk worm -gut sutures, the sound being in the
200
COLPOOLEISIS
bladder and the assistant's finger in the rectum
during the passing of the sutures The consent
of the patient and her husband must have been
obtained and the nature and result of the
operation explained
ColpOCystOtomy.-— An operation by
which the bladder is opened into by means of
a vaginal incision, this may be done foi
diagnosis, for the removal of a stone 01 tumour
m the bladder, or for intractable cases of
cystitis (when the incision is to be kept open
as an artificial fistula for some time)
Golpohyperplasla Cystica.— A
degenerative change m the mucous membrane
of the vagina, occurring sometimes in preg-
nancy, and ehaiacterised by thickening of the
mucosa with the presence in it of numerous
small gas-containing cysts, it was first de-
scribed by von Wmckol , it is probably due to
a gas-producing bacillus, and is therefoic really
emphysomatous vagnutis , and it is to be
treated by glycenno tampons
Colporrhaphy.— The operation (from
(l!r KoATros, vagina, and />a$»j, su Lining) foi
narrowing the vaginal canal by excision of
strips or areas of mucous membrane and the
approximation of the raw mil faces by sutmes ,
it may be earned out on the anterior vaginal
wall (antenat c)or on the posterior (posterior c ),
it may l>e associated with perinea! iep,iir (colpo-
penneorrhaphy) , and it is commonly performed
for the relief of tioublosome piolapsus uten
See PELVLS, PERINEUM AND PELVIC FLOOR (Pto-
fapsus Uten or Snero-pubie J/etnia) , UTERUN,
DISPLACEMENT ui> (Prolapse of the Uteiuv, Openi-
ColpOtOmy. — The opeiation of opening
into the peritoneal eavity through the uuterioi
vaginal formx (anterior i ) or thiough the
posterior fonnx (posterior c ) , vaginal section
it is a stage in various opoiations biieh as
vaginal ovariotomy, vaginal hysterectomy, and
vaginal hysteropexv See UTERUS, NON-\!ALIO-
NANT TUMOURS OK (Treatment of Fibroid*)
Col U bri ne. See SVAKE- BITES AN D POISON-
OUS FISHES (Coluhnie Swikes)
Columbia, British. See THFRA-
PEinics, HEALTH RESORTS (American)
Columna or Column.— A pillar or
tract or pillar-like purt of the Ixxly, ey the
columns of the spinal cord, of the heart
(columnar carneai), of the vagina, of the rectum
(columns of Morgaqin), etc See also BURDACII ,
CLARKR , (Sou, , TURCK , etc
Colwyn Bay. See THERAPEUTICS, HEALTH
RESORTS (Enylnh)
Coma. — A state of insensibility (horn Gi
lethargy) resembling deep sleep, from
\\hich the individual eithei cannot be roused or
can be roused onlj incompletely , respiration is
slow and stertorous, and generally irregular
It may be due to cerebral concussion, hcemor-
ihage, embolism, or thiombosiK, or to sun-
stroke, to alcoholic or narcotic poisoning, or
to uiwmia, diabetes, or meningitis, etc See
ALCOHOLISM (Acute, Alcoholic Coma) , BRAIN,
Ai-FEnioNs OF BLOOD-VESSELS (Haemorrhage,
Thorntons), BRAIN, HYPERTROPHY, BRAIN,
SUR«ER\ OF (Concusiiwi, Diagnose) , DIABETES
MELLITUS (Diabetic Coma), MALARIA (Pernicious
Attacli, Comatose Form) , MENINGITIS, EPIDEMIC
CEREBRO-SPINAL , NEPHRITIS (Clinical Features,
Netvous System), SUNSIROKE (Heat Fever),
ToxiroLOOY (Atcottol) , TIPIIOID FEVER (Symp-
tom*, Neivou* System), T\PHUS FE^ER (Period
of Advame, Neivous Symptom*), UNCONSCIOUS-
NESS, UR*MIA
Coma VlffIL— A lethargic state, in
which theie is unconsciousness combined with
sleeplessness and (sometimes) muttering de-
lirium (Sn W Jcnner), the phrase literally
signifies "wakeful deep sleep", it is a symp
torn which appeals geneially just befoie the
fata] termination of such diseases as typhus,
delirium ti emeus, etc , there is no stcitorous
bieathinir, the pulse is quick, the eyes are half
open, the pupils are not contracted, and there is
a certain degree of c onsriousness See TYPHOID
FENER (Symptom*, Net vow System)
Combined Degeneration of
the Spinal Cord.— A disease of the
spinal cold, occuriing m cases of profound
ancemia, and showing resemblances to locomntor
ataxia, disseminated sclerosis, and penpheial
neuritis
Combustion, Spontaneous. »sv
BURNS AND SPAT in (Medn<t~LewdA yiect*) — The
supposed binning of the human body from
accumulation of internal heat, as in the case of
drunkards , an exploded belief
ComedO.- -A black-head or black spot on
the skin of the face due to the letontion of a
hardened mass of sebum m a distended seba-
ceous gland, the mass of sebum can be c\-
piessed by picssuie on the Hiiriounding skin,
and has the form of a little yellow worm with a
black head (the bl.ick head is due to dut or to
pigment) Literally the Latin woid comedo
means a glutton, and the term used to be
applied to worms that devour the body »SW
ACNE, SKIN, BACTERIOLOGY OF THE (The Acne
Puitide)
Comes. — Literally a companion, is the
name given to any accompanying structure,
especially a nerve or \essel, eg arteria comes
nervi mediani
COMITIALIS MORBUS
201
Comltlalls Mor bus.— Epilepsy, so
called because if a case of epilepsy occurred
during the Hillings of the Roman Camilla,
there was an adjournment of the assembly, for
this disease was legarded as a punishment sent
by the gods
Comma Bacillus.— AVe CHOLERA, EPI-
DEMIC (Bacteriology), MICKO-ORGANISMH
Comma Tract of Schultze. -A
tract of fibres in the posterior columns of the
spinal cord in the cervical and upper doisal
regions, it lies between the columns of <»oll
and Burdach
Commensal ism.— Symbiosis or the
commensal stdto is that in whuh two animals,
01 plants, live together, the one as the tenant
(but not as a parasite) of the other It is
derived from Latin con, togothei, and menna, a
table
Comminution.— The bieakmg of a
solid body (e g a bone) into several small pieces
{eg A comminuted fracture)
Commissural Aphasia.— Aphasia
duo to destruction or interruption ot the con-
necting fibres between the different speech
centiea See APHASIA (Clintta/ Featwes, Com-
Commissure. — A joining 01 juncture,
the line \iheie two structures meet, or a con-
necting band 01 bundle (r </ the anterior com-
missure of the vuh.i, the commissme of the
eyelids, and the posterior commissure of the
ttpmal cord).
Common Lodging- Houses. See
LODGING-HOUSES
CommotiO. See CONCUSSION
Communicated Insanity.— The
rare cases in which theie is evidence that an
insane pcison has been the cause of a similar
kind of insanity in a previously sane pcison,
fohe a deu\ , double or induced insanity
Compatibility. See PRESCRIBING.
Compensation. See HEART, M\<>-
C \HDIUM AND ENDOCARDIUM (Phl/HCal til</H8 oj
Dijfeient Forms of Jletirf Disease), SPINE, SURGI-
CAL API-BCTIONS OF (Railway Spine, Compensa-
tion)
Complement. --A soluble ferment
which the phagocytes secrete dui ing mtracellular
digestion , an alexni , a cytase , the othei body
which helps the anti-body to act on the micro-
organism See IMMUNITY , PHYSIOLOGY, INTERNAL
SECRETIONS (Tojuc Actirms and Immunity)
Complemental Air. See PH\SIOLOQY,
RESPIRATION (Amount of Air Respn ed) , RESPIRA-
TION (Respiratory Rhythm and Rate)
Complexion. See CHIOROSIS (Symp-
toms) , SCURVY IN AbULib (Clinical Feature*)
Complication.— A morbid state \vhich
anses comcidently with .mother disease and
\N Inch is regarded as " complicating " it and
modifying its course (usually in the diiection of
making the prognosis worse) , but no hard and
fast line can be drawn between true complica-
tions (accidental occuirences) and the occasional
developments of a disease (e g nephritis in scailet
fever, diopsy in heait disease, etc )
Component. —An ingredient 01 con-
stituent element, e </ in a medical prescription
See PRESCRIBING
CompOS Mentis.— A Latin adjective
phiase meaning with power o\ei one's mind, in
one's right senses , soundness of mind
Composite Portraiture.-- A single
]x>rtrait produced by combining, by superposing,
those of two or more individuals , in this way an
average appeal ante 01 type may be obtained,
e g to show the ty pit al appearance of a tubci cular
subject (habitus phtlnsicus)
Compositor's Disease. *sv<- TRADES,
DANGEROUS (Lead Pawning), TOXICOLOGY (/nz-
tants, Lead)
Compress.— A pad of hnt or cloth so
folded and arranged as to make piessure on a
pait 01 to apply water or some medicinal sub-
stance to the surface of the body, A graduated
compiess is one made narrower and thicker at
the point where pressuie is specially required
Compressed Air Disease. See
CAISSON DISEASE, SPINE, SUU<,JPAL AFJECTIONS
OP (Caisson Ducase)
Compression. See ANFUR\SM (Treat-
itient, Digital and I n^tni mental Compression)
Compression of the Brain.— The
inoibid state, due to pressure on the hi am of a
tumour, a depressed piece of bone, 01 a blood clot,
in whuh there aio unconsciousness, stertorous
breathing, dilatation of the pupils, and paralysis
See BRAIN, SURGERY OF (Compi esuon) , SPINE,
SURGICAL AituuoNN OF (( 'ompi ewon Para-
plfqia) , nMONsriousMiHs (Cnmwwm and
Comjn e^ion)
Concato's Disease.— c.'onowi chiomc
inflammation of the scions membianes (peri-
toneal, pleura), pencardial, etc ) pol^orrho-
memtis or polyserositis
Concealment of Birth (of
Pregnancy). See MEDICINE, FORENSIC
(Infanticide)
Conception.— The act of conceiving 01
of becoming pregnant , also the thing conceived,
viz the ovum, embiyo, and foetus A false con-
202
CONCEPTION
ception is a blighted ovum, m which the gesta-
tion sac remains but the embryo hot* either dis-
appeared or was never formed See PREGNANCY,
PHYSIOLOGY, etc The words conception and
false conception are also used in Psychology,
with special meanings
Concha. — Concha (from Or icoyx1?! <l
cockle or shell) is the name given to the shell-
like part of the external ear between the tragus,
the ttnti-tragus, and the anti-helix, it is also
given to various other part*, of the body, e 7 in
the turbinatcd bones, and elsewhcie Com fat w
is inflammation of the aural concha
CondinatfOn.— A term, proposed by
Duano, for tilting of the top ends of the vertical
meridians of the eyes toward e«ich other, as
opposed to dwh nation (tilting away from each
othci)
Concomitant Strabismus. See
SFRAUISMUS (7V ue, Non -paralytic m Con-
comitant)
Concrescence. — The ombryological
process by which it is supposed that the edges
of the embryonic disc/ of the ovum at its
posterior end arc turned m, and the ptnnitive
streak carried forward and lengthened
Concretions.— Deposits or calculi, con.
sistmg, as a rule, of carbonates and phosphates
of lime, and foimmg m various organs (gall-
bladder, intestine, urinary bladder, prostate,
kidney, heait) and parts (joints, teeth, thrombi,
etc). See COLON, DISEASES OF (Dilatation),
GOUT , STOOLH, INTKSHNAL SAND
ConCUSSlOn. — The disturbance, even
the complete abolition for a time, of the functions
of the brain (ceiebial concussion) 01 of the spinal
cord (spinal concussion), or of both, due to
violent shocks, falls, blows, etc , which apparently
shake or jar the nervous tissues w ithout causing
other than microscopical lesions of the parts
See BRAIN, SURGER\ OF (Concuwon) , MEDICINE,
FORENSIC (Wound* 01 Injune*, Fiaituits of
Skull), UNCONSCIOUSNESS (Condition)
Condal Water. See BALNBOIXM.Y
(Spam and Portugal) , SODIUM AND us SAL is
(Sulphate)
Condensed Milk. See IM-ANT FEED-
ING (Condensed Milk), MILK (Dietetic, Con-
densed)
Condenser.— An apparatus tor condens-
ing the light, e </ Abbe's or Liebcrkuhn's condenser
(see MICROSCOPE), or a distillate, or electricity.
Condor's Process. — A method for
disposal of sewage by subsidence and precipita-
tion, water enters the sewer through a ferro-
meter containing sulphate of iron and a slice of
lemon , the method is in use at Chichester
barracks
Condiments. — Accessory articles of
diet which make food appetising, and so probably
inciease the flow of gastric juice Some of them
arc aromatics (e y nutmeg), others are alliaceous
(mustard), others acid (vinegar), others salty
(common salt), others sugary, and others are
the peppers
Condom. — A thin bag of mdiarubber,
caoutchouc, or goldbeater's skin worn over the
male organ during coitus to pi event impregna-
tion taking place } a check , said to be derived
from the name of the inventor (Conton)
Conduct. — "The active or dynamic ad-
justment of self to ciicumstauces" (C Metcier,
I/acl Tuke) , upon deviations from the noimal
of conduct or belhiviom the alienist has often
to base his diagnosis of insanity Sec INSANITY,
ITS NATURE AND SYMPTOMS (Mental Functions,
Conduct)
Condurango.— T
bianco, A South Ainoiitan \mo, once recom-
mended foi cancer and still used in syphilis (not
othcial)
Condyle.— Condylc (from Gi icdi/SvAos, a
knuckle) means a louiulod ptoccss on a bone
which serves to fonn pait of the aiticulation
between it and auothct bone, c</ the tondylcs
of the femur, of the lowei jaw, of the occipital
bone Condylotomy is osteotomy of one 01 both
condyles of the femur
CondylOIIia. See S\ IMULIS (Second*) y) ,
UMBILICUS, DISEASES OF (Syjihthb) , LARYNX,
CHRONIC IM-ECTIVE DISEASES (
Condy'S Fluid. — A ied fluid said to
contain 8 grains of permanganate ot potash to
the fluid ounce of distilled ^ater See DIHIV-
ikrrioN , MANGANJJ.HIUM, POIAHHIUM AND ire
SALTS (Potawi Pn mam/anai)
ConfeCtlO. — A paste containing a dis-
agreeable medicine com}x>unded with sugar or
honey to make it less nauseous, e q the Confectio
Senn<p , an eluctuaiy or conserve See PRB-
Confinement.— Detention at homo or
in a hospital or asylum on account of illness , it
is usually regarded as synonymous either with
childbirth, lying-in, delivery (accouchement), or
with forcible detention in a lunatic asylum
S« PUEONANCY, DIAC.NOSIS (ProljojMe Date of
Confinement)
Confluent. See SMALLPOX (Clinual
Variation^, Variola Confluent)
ConfUslon. See GENERAL PARALYSIS
(Symptom*, Stadium Acntttm) , MENINGITIS,
CONFUSION
203
EPIDEMIC CEREBRO-SPINAL (tiymptonis, Psychical
Confusional Insanity. #«• IN-
SANITY, ITS NATURE AND SYMPTOMS (Type*, De-
lusional Insanity, Confusional)
Congelation, .sv? UAM.RENK (/w-
lite)
Congenital. — Present at the tune of
birth »SVf AMBIAOI'IA, CAPILLARIES, DISEASES
OF (JTcnitM), CATARACT, Ciioitoii), DISEASES OK
(Congenital) , CORNEA (Cow/enital Upntitin),
\)Ei>oRmnEn (Congenital Dislocation*, it< ), K^F-
LIDS, AFFECTIONS (Distichi<i*i*>, etc ) , ULAIU,
CONGENITAL MAIIOHMAFION'S OT , HRRMA (Con-
genital) , KIDNEY, SURGK'AL Ai i LCTIONS (Hydro-
nfphrotu) , LACHRYMAL APPAHMUH, DISEAS** 01
(RleniunrhaMi) , LAW NX, ACUTE AND CHROMU
IXI-LAMMAUONS (Cont/enitttf (rlottlt NtfntiM*) ,
LAR\\\, CoNGfcNMTAL LJUtt \GFALSlKIDOR, MEDI-
ASTINUM (Tumouis, Congenital Cyst*) , MBMOIU
IN II LAI 111 AM) DlStASh (Coiigniltal Deftf ts) ,
MfcNSTRLATioN AM) ITS DisoRDFiis (Congenital
Atretia) , MENTAL DKMCIRNC^ (Clarification,
Congenital) , MORFHIXOMANIA (Congenital Jlabi-
htes) , MuhTiJut, DISFASES OF (Congenital Ab-
sence) , M\ASIH*NIA (TRAMS (Cvnijmitaf Ah-
nw nullities), NAILS, AIIFCTIONS oi< (Conaentlal) ,
OCULAR ML,srLi-s, AHECIIONS OF (Congenital
Xyxtaqiiin*, eti ) , ( ESOPHAGUS (Dilatation and
/'oiic/ie*) I1 \IIAIA sis (Coni/emtal Hftastu, Coti-
t/ftntal Vhmea, ft< ), PKW.N-^N^, I\iRA-l ifcRiNE
T)ISEASFH , ULIINA AM>Opnr NFRAE (Congenital
Abnt*mnhtif\) , Siion IIKU, DISF\SKS OF (Cott-
(/emtal Detot*) , S'IOMA< n \M) DLODFNUM, Div
or (Ify}ieitif>jihy of 1 'i/loni*) , Tnu-
Conger. ^SNAKF-RIIPS \NJ> VoihONois
FISHES (Fibh </<» 7/osfs fot Jfydatuh)
Congestion.— llyper.eium, 01 AH c>\-
tGHbive OLCiiiunlHtioii of blood in any j)«ut 01
organ (eg the uterus, liver, kidneys, or brain) ,
it is not, btnctly speaking, synonymous >\ith
infl.uunmtion
Congo SickneSS. ^ SLEEPING Si< K-
NESS OR NEGRO LETHARGY
Conhydrlna. — A veget<iblo alkaloid
(CRHirNO), contained in hemlock S<c ALKA-
FOIDH, CONIUM
Conical Cornea. &e CORNEA (Comcal
Cojnea)
Con Id la. Kee MICRO-OKGA \ISMS (Hvpho-
mycetes)
Conine. /SVe ATKAKUDS, COMUM
Con I um.— Both the leaves and the fruit
of Coniwn nwrulatum are official The mobt
important constituents are — (1) Conine, an oily
liquid alkaloid, \vhich has a strong depressing
action on all motor nerves, and eventually on
sensory nerves also, (2) Methyl-conine, a fluid
alkaloid, with a depressing action on the spinal
cord , and (3) ConJtydt me (a v ) The prcpara-
tionb of Conium vary greatly as to the relative
and absolute amount of these two principles
present, and their effects arc consequently un-
reliable Wie preparations are — 1 From Conn
Ftuctui, Tinctura Conn Dose — J-l ~, 2 From
Conn Folia — (1) Succus Conn Dose — 1-2 3
(2) Unguentum Conn, made from the succus
Conium has occ.ision.illy appeared to be of
service in punful stomach conditions, and, as
a temporary expedient, in asthma, chorea, and
othei spasmodic affections, \\hen accompanied
by restlessness and insomnia It has also been
ii^ed in tetanus and epilepsy, but its value in
these diseases is oxtiemcly doubtful Conine is
too strongly alkaline to be given hypoderimcally,
but u hytliotti ornate has been employed for this
purpose in doses of fiom \-\ gram
Conjugate or Conjugata.— The
conjugate oi an ellipse is the minoi axis or dia-
meter, thcicfoic at the brim of the pelvis the
conjugate is the antero-postcnor diameter , the
anatomical conjugate is diawn from the sacral
piomontory to the outer edge of the upper
}>oidor of the symphysis pubis, and the ob-
itetrual conjugate to the inner edge, or to a
point just below it, where the joint bulges
slightly backward into the bum (the latter has
been called the cvnjuyata minima) , the diagonal
conjugate is measured from the sacral piomon-
toiy to the lo\vci bolder of the symphysis pubis,
and the eitetnal conjugate (or Itaudelocque's
dianictei) is measured fiom a point just below
the spmo of the last lumbar veitebra posteriorly
to the antenoi surface of the symphysis pubis.
Kee (ihNLKATrov, FEMALE ORGANS OF (J'elws,
Dtametet*), LABOUR, OPERAIIONS (Induction)
Conjugate Deviation.— The per-
sistent turning of the eyes to one side \\ithout
tiny alteiation in then lelationship to each other,
e (/ auay from the paralysed side in hcmiplcgia
tSee OCULAR MLS( i ES, AH-ECTHONS u» (J'atalyatt),
MBNIN(.IIIS, TUHLRCUI ous (
204
204
205
205
209
209
210
211
211
Conjunctiva, Diseases of.
ANATOMY
M \L101iMAl IONS AND CoNGhNNAL AiNOM-
AL1KS
INFLAMMATORY AVI-KTIIUNS-
Atnte Ophtluilimit
Muio-jnn idi'nt, /'urultitt, Acute
(itanular, Mtinbtanun*
Chtonic Ojththalnua
Chiomc Mtu.o-jmiitltHt Con-
junt ti vifm, Foil u ulat Con-
'jututivitu, Tnuhn»M
J'hlyttfnulat Conjunct intu
Njniiui C atan k
JKjranthematov* Conjunctivitis
'204
CONJUNCTIVA, DISEASES OF
TUBERCULOSIS 211
SYPHILIS 212
Ophthalmia A o<hw '2 1 2
DEGENERATIONS -
Xeioms, Pem/tJii</u<tt Lnrdaifow
DeqeneiatioH, (1otifunftiviti\ Petn-
ftcans 212
VARIOUS CoNimioNt —
Ptet yq\ urn, tiymMejthtn on, Pini/uerttfa,
EffuwMV into the Conjunctiva,
tftaimnf/ of, L\Hnn^i\ Conjunrti vitti
ftom Da^zhwf, Bmphyvmfi 213
TUMOURS OK 214
INJURIES OF 214
See alvo ASEPTIC TREATMENT OP WOUNDS
(Conjumtiwi) , BRAIN, AFFECTIONS OF BLOOD-
VESSELS (Uyperirmta of Rrain, Symptom*,
Injection of Conjunctiva) , CONJUNCTIVITIS,
CORNEA (Ulcet atton) , DIPHTHERIA (Conjuncti val) ,
GLANDERS, FARC* (Symptoms in J/<m) , HYSTERIA
(Sensory fiwordet *, Ocular) , HERPES (Ocu/at
Complications) , MENSTRUATION AM» ITS DIS-
ORDERS ( Vicarious Menstruation) , MYIASIS
(fify-ians Conjunctive?) , NEPHRIIIS (Chtonn,
Watery Appeal wire of Conjunrtim)
ANATOMY ot THK CONJUNCTIVA
THE conjunctiva externally is continuous with
the skin at tho fiee edge of the eyelids, and
internally with the Schneidenan membrane by
way of the laerymal ducts The pinkish
palpebral conjunctive is hnnly attached to the
inner surface of the eyelids, and is connected
with the ocular conjunctiva by the rctro-tarsal
folds, one abovu and one below, which by their
loose arrangement prevent any dragging upon
tho lids by the movements of the eyeball The
ocular Conjunctiva lies upon the antcnoi part of
the sclera , it is pale and thin enough to allow
the sclera to be seen through its texture It is
loosely attached to tho underlying sclerotic,
so that it may bo readily picked up with
forceps By a sort of reduplication it forms
towards the inner anglo of the eyelids a more
or less vertical fold, tho plica seimlunaiis, a
vestigial relic of the third eyelid of certain
lower animals The small reddish mass, often
covered with fine hairs, which lies between the
plica and tho inner commissure of tho eyelids,
is called the caruncle Around the cornea the
ocular conjunctiva becomes closely knit to the
underlying sclera, and forms what is known as
the hinbus conjunctiva1, a position in which
blood -vessels are especially numerous The
conjunctiva coveis the anterior surface of the
cornea, but in that position it is reduced to a
few layers of epithelial cells The nervous
supply ot the conjunctiva comes from branches
of the fifth cranial nerve , the vascular supply
mainly fiom the posterior ciliary vessels The
lymphatics comprise a superficial and a deep set,
with communicating branches
MALFORMATION'S AND CONGENITAL ANOMALIES
Filno- fatty Tu mour. — S\ N Subconjunctival
Lipomn <n Lipo-dermoid — This congenital
anomaly is not uncommon, but as it generally
causes no maiked defoimity, it falls compara-
tively seldom under the notice of the surgeon
The tumour takes the form of a soft, slighth
laised yellowish mass, moie 01 less triangular in
form, and usually occupying the interval be-
tween the superior and the external rectus
muscle It lies beneath the ocular conjunctiva,
and is fieely movable upon tho globe As a
rule, its imestmg conjunctiva appears normal,
but short hairs may be present, a condition to
which the name tin host,* biilln has been applied
There are a few cases recorded where a tumour
occupying the customary position of a hbro-
fatty growth was found to contain an osseous
nucleus, in some instances covered with peri-
osteum I believe, as a lesult of microscopic
investigations of those cases, that they are
probably of a del moid nature, and •when they
contain bone should bo classed as teratoma
Treatment — When inconspicuous these
growths are best left alone Otheiwise, the
conjunctiva may be reflected, and some of tho
exposed fatty - looking material snipped away
with fine curved scissors The conjunctiva is
afterwards replaced, and kept in position by
inserting a continuous sutuie
Dermoid Turnout* — Tho ordinal y dormoul
forms a solid pinkish -white growth, usually
situated at the lowei and outer part of the
sclero-corneal junction, and encroaching to a
\aiiable extent upon both cornea and con-
junctiva It is attached firmly to the cornea
Hairs may or may not grow fioin the deimoid,
tho top of which is now and then dry and tatty-
looking The tumoui (generally limited to a
single eye) is usually about the si/,e of a split
pea A case has been reported, nevertheless,
where the giowth had reached tho bulk of a
hoise-bean, while upwards of twelve long bans
grew from its middle part, passed between the
cychdH, and hung upon the cheek The patient
remarked that these hairs did not appear until
he was sixteen years of age, at which time also
his beard grew The dormoid often shows a
distinct tendency to get larger, and to become
hairy at or about puberty Tho microscope
shows that those growths include tho elements
of ordinal y skin, as epithelium, glands, hair
follicles, etc
Tteatment — The giowth may be removed by
ciueful dissection
JVceiw — Angiomata, plexiform or cavernous,
may involve tho conjunctiva, and are usually
associated with a similar condition of tho eye-
lids, orbit, face, or of other parts of the body
Tho commonest clinical appearance is that of a
small or large patch of purplish-red discolora-
tion affecting the palpebral mucous membrane
CONJUNCTIVA, DISEASES OF
205
More rarely a definite tumour is met with,
involving, it may be, the semilunar fold or the
ocular or the palpebral conjunctiva In some
of these cases the angioma foims a livid,
nodulated mass, bleeding on slight provocation
Treatment —Small capillary nam, which give
rise to no dishguicment, call for no special
treatment unless they sho\v a tendency to get
bigger More conspicuous patches may be
seared with the galvano-cdutery, or (after care-
fully drying the paits) be painted lightly with
solution of sodium ethylate (B P ) until mipiove-
ment icsults The cavernous angiomata arc
best dissected out, an operation that is by no
means so diihcult as it seems
Lymphatic wuix is a tare but interesting
congenital condition which depends upon dilata-
tion of the lymphatic vessels, with hyperplasia
of the conjunctiva Some part of the ocular
mucous membrane is occupied by a bunch of
small yellowish elevations, \vhich convey the
notion that they contain fluid The mass may
undergo vanations in size, particularly in
females at the menstrual period In a case of
my own the appearance reminded one of a non-
inflammatory chcmosis, ot yellowish colour,
occupying the ocular conjunctiva on the n.isal
side of the eyeball In anothei case a pi eminent
mass of yellow-like tissue, dotted ovei with tiny
hicmorihagic points, was connected with the
scmilunar told, while in the same eye theie \vas
a collection of yellowish beaded vessels in the
uppei part of the ocular eonjunctua Both lids
wcie thickened, presumably from 1 \mphatic
obsti action The eyeball was small, shieds of
persistent pupillaiy membiane were piesent,
dotted opacities were diffused thiough the
ciystallmo len», and sight was extiemely poor
Alt examined microscopically an instance of
lymphatic vanx, and found in the ocular con-
junctiva a seiies of (anals and cavities, the walls
of which weie lined by endothehum and foimcd
by the compiessed fibres of the conjunctival
tissue
Mole* have been descnbed as existing upon
the ocular conjunctiva
Sitpeinumemty Oat uncle — It appeals that
the caiuncula laci> mails, like the tragus or the
nipple, may be duplicated The first observa-
tion of the kind was published by the wntcr in
1896, and since then l)r J W H Eyio has
recorded two similar cases A small, raised,
fleshy mass, of gianular appearance, is attached
to the conjunctiva of upper or lower lid some-
where near the normal caruncle , fine hans may
be piesent on the suiface of the giowth
Treatment — Should it be desired for aesthetic
reasons, the little tumour may readily be snipped
away with scissors Recurrence is unlikely
Other Rare Affection* — The writer has seen
perhaps half-a-dozen instances of a peculiar
congenital growth, which, so far as he is aware,
has not been mentioned in literature A greyish
red tumour, oblong or remform in outline,
occupies some part of the ocular conjunctiva.
It is freely movable with the conjunctiva in
which it lies, a few dilated vessels often run
towards it Micioscopically it seems to be of
cystic nature, its wall being formed of a thick
but irregular stratified epithelium, together with
a vascular subcpithelial layer of connective
tissue The tumour is easily dissected out, and
if the wound be carefully closed with a con-
tinuous suture, scarcely a trace of the opeiatiou
remains
I\ * LAMM ATOUY AF* BC I IONS
The conjunctival sac, even in a state of
health, is seldom altogether free from micro-
organisms, of which by far the commonest is
the so-called xerosis bacillus , the staph^lococcus
pyogenes albus (or the staphylococcus epiderrm-
dis albus) is also often found Certain other
miciobcs arc present under morbid conditions,
as, foi example, gonococci, Weeks' bacilli, pneu-
moeocci, diplobaulli, bacillus coll commums,
diphtheria bacilli, and vaiious pyogenic cocci
They give rise to definite conjunctivitis, the
dugnosis oi which is nowadays made chiefly
fiom a bactei lological examination Although
0111 knowledge of the parasitic nature of acute
ophthalmia is fairly complete, the same cannot
yet be said of the chronic forms, especially of
trachoma
A<vir Oi'imnnin
\h stated above, in our present state of
knowledge it is possible to asciibe nearly every
known form of acute ophthalmia to the action of
specific miciohes At tin same time, to avoid
confusion, we may retain the classical clinical
divisions and speak of 1 Muco - pin ulent
ophthalmia , 2 Purulent ophthalmia , 3 Granu-
lai ophthalmia , and 4 Membranous ophthalmia.
1 MuooPuKur KNT OPHIHALMIA — This com-
mon affec tion tends to become epidemic in spring
and summei, and at tunes it is extiemely con-
tagious No age is exempt, although it is,
above all things, a c hildish ailment
Etiology — It is associated with several
distinct micro-organisms, of which two are more
widely spiead than the rest put together, namely,
(a) the shoit and slender bacillus descnbod by
Koch and Weeks, and (I) the diplobacillus to
which attention was dnccted by Morax a few
yeais ago In some othei countries, however,
it would appear to be more generally due to
pneumoeom It is sometimes set up by the
bacillus coli communiH, as well as by the various
pyogenic cocci, as the staphyloeoccus aureus,
citreiiM, and albus, although in the case of the
last-named a special predisposing condition of
conjunctiva is probably essential to the oph-
thalmia I have met with one case (associated
with an evil - smelling dischaige) where the
bacillus pyogenes fcctidus appeared to be the
206
CONJUNCTIVA, DISEASES OK
cause. But, on the whole, wo may with toler.ible
confidence Hay that a severe muco-purulent cou-
junctivitia m this country is likely to he duo to
Weeks' bacillus, whereas a much milder sub-
acute form is probably associated with the diplo-
bacillus of Morav In my experience, the othei
organisms named above are comparatively iaie
as causes of conjunctivitis
Cftaiacfei* — The upper hdh are reddish and
putted , the ocular conjunctiva is bloodshot and
perhaps ecehymosed , the palpebral conjunctiva
is umioimly red .md lather swollen, and its so-
called "follicles" (see page 209) aie often
peculiarly prominent Yellowish discharge is
found about the eyelashes, at the innci canthus,
and, mixed with lacrymal fluid, in the recesses
of the conjunctiva Ohemosis is seldom a marked
feature Phlyctonulaj about the conjunctiva or
elsewhere may be present The patient com-
plains of his eyes feeling hot and heavy, as well
as of a sensation which he often 1 ikons to sand or
dust in the eye , a degiee of photophobia is not
rare In uncomplicated eases the coinea is
clear, the ins bright, and the pupil mobile
Speaking generally there is little tendency to
corneal mischief, especially in children YVhe.ii
the inflammation is caused by the pneumococ cus
there is apt to bo a thin, hbimous deposit upon
the conjunctiva of the upper lid The special
sign of diplobacillaiy inflammation (m addition
to its subaoutc character) is angular blepharitis
— that is to say, an excoriation and soieuess of
the innei and outer canthus Pus infections
are observed in children sufteimg from a coinci-
dent impetigo or discharge from the ear Tho
bacillus coh sets up an acute conjunctivitis
which has no distinguishing feature beyond its
tendency to subside spontaneously
Treatment — The punciplcs are — first, to
kill the pathogenic organisms by the local
application of antiseptics , secondly, to remove
morbid secretions , and thirdly, to relieve special
symptoms, such as pain The best remedy for
all severe cases is a 2 per cent solution of silver
nitrate applied to the exposed conjunctiva once a
day The acutcr symptoms seldom w ithstaud more
than three or four applications, but the remedy
should be persevered with until microscopical
examination shows discharge to be free from the
specific organisms The same agent succeeds
m most of the remaining acute muco-purulent
inflammations of the conjunctiva, except possibly
in that due to the diplobacillus The latter is
best treated by means of a strong solution of
zinc sulphate (gi 10 to the ounce) dropped over
the conjunctiva three or four times a day
Chlondo of zinc (gi 5 to the ounce) may also
be used with success For removing discharge
from the eye, a saturated solution of boric acid
or corrosive sublimate (1 5000) succeeds ad-
mirably The liquid should be applied at or
about body tempeiature, and the lids, when-
ever possible, should be everted. Pain, when
at all severe, may be relieved by the local use
of a I per cent solution of cocaine hydrochlonde,
dropped into the eyes at intervals of a few
hours In severe cases it may be necessary to
give bromide oi potassium or chloral internally
2 I*URULK\T OPHTHALMIA — This ailment
results fiom the gonococcus reaching the con-
junctival sac It is extremely contagious
J'atJtvloyttally, it is characterised by dense
cellular infiltration of the subepithelial tissue,
and by gieat thickening o( the suiface epi-
thelium, m which, by suitable means of harden-
ing and staining, active kaiy mitosis can be seen
The gouococci do not penetrate the mucosa
much deeper than the epithelium, most of which
is sooner or later shed The following points
may be noted with regard to gouococci and their
relationship to cases of purulent ophthalmia —
(a) They are scanty to begin with, but become
numerous when the dischaigo gets pi of use , (6)
the thicker the secretion the greater their
number, (c) they aie not seldom mixed with
xcrosis bacilli and with pus organisms , (<{) they
may persist foi scveial weeks In practice
purulent ophthalmia is met with under two
forms, as it affects (I) newly-boin childien, and
(2) older subjects The clinical differences
between these varieties render a sepaiatc dc-
scnption desirable
(1) Oi'iiniAKMiA XKONATORUM — This usually
develops on the second oi third day aftei birth
Earlier cases aie attributable to a lingering
labour in which the infant has been infected
during the act of parturition, and latei ones to
inoculation fiom contaminated lochm Material
in the maternal passages, containing gonococci,
clings to the babj's lashes, and is earned into
the eye after birth, either by the blinking of
the infant, or by the sponges, water, 01 other
articles employed m the first bath Its leading
feature is a discharge, at fust thin and whej-
hke, and later resembling pus As the case
advances the eyelids aie greatly thickened by
serous effusion, and when thus swollen they
tend to become everted when the baby cries
The palpebral conjunctiva (otten difficult to
expose) is red, thick, folded, and has a villous
look "like a finely - injected fojtal stomach"
(J C Saundcrs) Chemosis, howevei, is not
common In this dangerous affection the cornea
may be rapidly mvoh ed, particularly m prema-
tuic or syphilitic infants, an abnormal tight-
ness of the eyelids also is unfavourable to
lecoveiy The baby, in marked cases, is often
fretful, while diarrhoua is apt to come on,
especially if the infant is bottle-fed The com-
plications include swelling of the preauncular
glands, abscesses about the eyelids, purulent
discharges from the external genitals of female
children, arthritis, and (rarely) inflammation of
the serous membranes Common results are
cicatricial changes in the conjunctiva, opacities
of the cornea with or without inclusion of the
CONJUNCTIVA, DISEASES OF
207
ins, anterior capsular cataract, nystagmus, and
squint 1
Treatment — Discharge must be rciuo\ed
fiequently by meant* of antiseptic lotion, as
corrosive sublimate (1 5000), mercuric cyanide
(1 1000), potassium peimanganate (1 1000),
naphlhol (1 5000), boric acid (saturated solu-
tion), or chloune watei The application should
bo warm, and applied to the everted conjunctiva
with a morsel oi absorbent cotton- wool A
syringe should not be used for the puipose,
bince it is capable of doing mischief to both
patient and opciator In bad cases, dining the
height of the attack, the baby must be tended by
the nurse day and night, as cine depends chiefly
upon the caie with which the eyes arc kept
clean Iced applications to the eyelids find
favour in some quartets, but they call foi much
attention, tend to confine pus, and are difficult
to keep in place On the other hand, the
palpcbial conjunctiva, may be painted with a 2
per cent solution of silver nitrate niespcctne of
the stage of the disease The solid silver stuk,
whether mitigated 01 otherwise, cannot be
recommended, as its use is almost certain to be
followed by uleeratiou of the (onjumtiva The
bihei solution may be applied once a day, or
even twice in seven* rases There are two othei
remedies that may be substituted foi silvei
nitrate, namely, ptotaigol (50 per cent) and
largm (5-10 pci cent), both of \\huh .no
synthetic compounds of silver and proleid sub-
stances They .11 e used in the same way as the
silver nitiate -that is, upon lids c vetted and
carefully fieed fiom discharge The use of one
or other of the fotegoing picpaiations should be
continued until the discharge gets thin and
scanty, and is found no longer to include
gonococci The remedy is then to be employed
twice 01 tht ice 11 week for a longei term, so as
to a\oid all nsks ol i elapse If the coinea be
hazy when the case comes under notice, physo
stigmine should be dropped into the eye three 01
font times a dtiy — 1'hysostigmm sulph , gr 2 ,
cocam hydiochloi ,gi 5, distilled water, 1 ounce
Atropine sulphate (gi 2 to the ounc e) may be used
instead of physostigmine when the coinea is
actually ulcerated Should the ulcci be deep 01
have yellow edges, oi should thete bo pus in the
an tenor chamber, then moic vigoious mcasmes
must be taken without further delay Foi
example, an anaesthetic should be given, and the
ulcei either fiecly seaml with the galvano-
cautcry or else thoroughly touched with the
liquefied carbolic acid (B P ) These operations
may have to be icpoated
(2) PURULENT OPHTHALMIA IN OLDER SUB-
JECTS — This affection dine is fiom ophthalmia
1 It must bo borne in mind that forms of ophthalmia
other than those caused b> gonococu are met with in
babies The wiitei has found gououxci in 66 per cunt
ol liu CUMJ>>, m the others, Weeks' bacilli, diplobacilli,
piieuinocotti, or bacillus coh communis appeared to be the
cause ot the inflammation
neonatorum in the follow ing respects — (i ) It
is generally confined to a single eye , (n ) it
affects men more often than women, (in) its
prognosis, especially in persons over twentj
years of age, is very grave Its most frequent
cause is auto -inoculation from a coexisting
gonorrhoea The vnus is spread by fingers,
washing materials, bed liucu, or contaminated
instruments 01 dressings , m hot countries flies
appear to be the mast Ubiial agents of infection
Kymptonw — After an incubation period aver-
igmg about two days, the disease declares
itself by pain, photophobia, swelling of the
lids, and the dischaige of thin, whey-like
mateiial fiom the conjunctiva The eaily signs
ire so little chaiactcustic in the absence of a
clear history of inoculation that the case may
be re.uiily mistaken for one of catarihal in-
flammation, unless the secretion be examined
with the micioscopc and found to contain gono-
cocti But before long the conjunctna of the
eyelids becomes markedly swollen, villous, and
of a deep -red hue, that of the eyeball is
infiltrated with serum, so as to form a mound
of jelly -like thickening around the cornea
(diemosis) Lancinating pains are common,
and the eye may be exttemely tender Mean-
while the abundant discharge is thick and
yellow, and includes innumerable gonococci
After a few days the swelling of the lids and
conjunctiva be tomes less marked, and in most
cases the condition slowly recedes The pro-
cess, howevet, when sevete, almost always sets
up more or less conjunctnal scarring The
cornea may suffer eithei eaily or late The
earlier and much mote dangerous ulcetations
.ire to be suspected when there is much
chemosih, but aie generally discovered only
when the swelling of the eyelids has begun
to go down A d ulness is obscncd either in
the intci palpehral /one 01 else in the central
legion of the cornea, and, while in a few
instances the piocess may go no faither, usually
the gieyish aiea becomes convex ted into an
actual ulcci The latter may be clear or have
a yellowish look, in which event it is likely
to pet foi ate the (ornea, a staphyloma resulting
The latei ulceiations may be central or pen-
pheial, but suitable means will generally pt event
their spread, especially when they show any
tendency to \asculanty The affection, like
ophthalmia neonatorum, may be associated
with, 01 followed by, inflammation of the
joints, as in a case related by Weiss and
Klingelhoflet Indeed, theie is no leason why
the othei complications named on a former
page should not also occur
Ttentnient — Jn principle, the treatment of
oidmaiy gonoriho?al ophthalmia does not differ
from that of the same affection in babies The
results, unhappily, are nothing like so favour-
able The patient must be put to bed, and
the pain leheved by sedatives or narcotics
208
CONJUNCTIVA, DISEASES OF
During the earlier stages iced compresses of
corrosive sublimate lotion (1 5000) may be
applied to the swollen lids Discharge must
be removed with one or other of the weak
antiseptic lotions mentioned The plan of
irrigating the conjunctival sac with large
quantities of a diluted lotion of permanganate
lotion with a special irngator deserves a trial
Gonococci must be destioycd by the applica-
tion, once or twice a day, of silver nitrate
Eper cent), piotargol (50 per cent), or largin
•10 per cent) Those remedies, however, must
used with great caution until the discharge
assumes the characters of pus Conical com-
Sicatious must bo treated with atropmc drops
r 2 to tho ounce), or with the galvano-
cautery, as desciibed elsewhere Should a
"granular" state of the conjunctiva succeed
the acute disorder, the sulphate of copper
stick, applied daily, will be found the best
remedy. When one eye alone is affected an
attempt must be made to save the other from
invasion The most satisfactoiy plan may be
briefly descubed as follows — A watch-glass
crystal is enclosed between two pieces of
adhesive plaster, in which holes have boon
cut This contrivance (mtioduced by Dr
Bullei) is then fastened m front of the sound
eye, which can by those means be inspected
at mteivals without the nsk of its being
touched by hngois contaminated with gono-
cocci As a further safeguard, the patient, as
far as may be, should ho npon his affected side
3 ACUIK GRANULAR OPHTHALMIA — Granular
ophthalmia or trachoma (w p 209) is essentially
a chronic affection, subject to acute exacerba-
tions The clinical appeal ances in acute cases
vary much, but one feature w common to all,
namely, the development in the palpobral con-
junctiva of many "sago -grain" granulations
A bacteriological investigation of the seeiction
has in about two-thuds ot my cases icvealed the
existence of an oigamsm indistinguishable from
Weeks' bacillus, and this is doubtless the
microbe recently described by Dr Lropold
Muller as the specific cause of the malady
Its presence may be explained by an outbreak
due to Weeks' bacillus occurring in a com-
munity \vheie trachoma was pievalent A
mixed infection is thus set up, which manifests
the clinical picture of an acute or subacutc
trachoma Tho disease is invaiiably followed
by chronic ttachoma
Treatment is thatof muco-purulcnt ophthalmia,
and, later, when chronic, that of trachoma It
must never be forgotten that acute trachoma is
one of the most contagious inflammations of the
eye, so that early isolation is of vital importance
4. MEMBRANOUS OPHTHALMIA — Several dis-
tinct forms of ophthalmia may be associated
with a membiane upon the conjunctiva The
Klebs-Loffler bacillus may give rise to a slight
or to a sevcie form of inflammation under
conditions that are as yet obscure The milder
form has for yeais been known as croupovs, and
tho moie severe and less frequent as diphtheritic
ophthalmia The two affections are more
fioquent in young children, and tend to follow
closely zymotic ailments, such as measles and
scarlet fever
(1) Cioupous ophttudmia is not unlike a
lather severe form of inuco -purulent con-
junctivitis set up by Weeks' bacillus. The
lids, often a good deal swollen, can be readily
everted, and strings of glutinous secretion
frequently stretch from one lid to the other.
The ocular conjunctiva is congested, and may
be slightly thickened The striking feature of
tho atiection, however, lies m tho grey mem-
branous exudation upon the palpebial and
(more raiely) upon tho ocular conjunctiva
The membrane can be s tupped away, exposing
beneath a thickened, red, and bleeding surface.
There may be spots of diphtheiitis about tho
lids, nose, or face , tho preauricnlai and angular
glands may bo involved, the geneial health is
usually good The disease is not followed by
symblepharon 01 by cicatncial changes m
the conjunctiva The prognosis is favourable
Croupous ophthalmia is comparatively common
in London
(2) Dtj)hthei itic conjun<tivitit> has a clinical
appearance so characteristic that a diagnosis can
often be made at sight The discharge, at hist
thin and scanty, after a few days tuins to a
thinnish pus, in which lie shreds oi necrotic
tissue If the swollen lids can be evcitcd, the
palpcbral conjunctiva will bo found firm and
lardaeeous, or "brawny," either thioughout or
in patches A maiked tcatuie is tho picsenco
of depressed, greyish- white aioas, associated
with small, daik-rod, ccch;yinotic spots Tho
bulbar conjunctiva and tho cornea may be
coveiod with false membrane Tho affection
is followed by cuatncial changes and deform
ities of the lids Diphthena of the fauces or
elscwheio may piecedc, accompany, or follow
the ophthalmia The patients, w ho .ire seriously
ill, show such symptoms as raised temperature,
frequent pulse, depiession, aniumia, albumin m
the urine, and loss of knee-jerks. A sequel is
peripheral neuiitis, as shown by patesis of the
palate, ocular muscles, extremities, and so on
The disease is very rare in England
Treatment — If the clinical evidence of diph-
theria is stiong, antitoxin should be used with-
out waiting foi the results of a bacteriological
examination otherwise the injection may be
deferred for a time Wheio Klcbs-LotHcr bacilli
aie found, antitoxin should be immediately
administered The effect of the remedy, when
used early, is remaikable. Experience has
pioved that antitoxin alone c fleets a cure. It
is advisable, however, to employ local treatment
as well — first, to hinder tho absorption of
toxins, and, secondly, to destroy organisms,
CONJUNCTIVA, DISEASES OF
209
other than Klebs-Lomer, that may bo present
For this purpose, in the caiher stages, the
writer prefers a 15 per cent solution of potassium
permanganate, and, Liter, a 2 per cent solution
of silver nitrate The remedy selec ted must be
applied once or twice daily, if possible, to the
everted conjunctiva Meanwhile the eyes must
be kept clean with an antiseptic lotion, such as
coirosive sublimate (1 5000), or bone acid (1
per cent), 01 quinine A good formula IK quinine
hydrochlonde, gr 2, distilled water, 1 ounce
Stimulants are often needed in seveie cases
The patient must be carefully isolated, especially
from other children
ClIRONH ' Ovn I'lfAL MIA
Three forms of conjunctivitis are included
under the general description chronic ophthalmia,
but befoie describing them, a few words must be
said with regaid to the healthy palpebial eon
junctiva The lower taisal membrane is genet
ally traversed bv arborescent vessels, and shows,
especially towards its outer side, a number oi
minute transparent elevations, the so-called
"follicles," which are neither more nor less
than collections of small round cells Vnothei
common appearance consistent with health is
that ot a single low of mmiu> elevations, \vhich
lie close to, and paiallcl with, the fiee edge of
the outei thud of the eyelid The uppei tarsal
conjunctiva may be smooth 01 slightly velvety,
particularly along its lo\\oi convex edge It is
of so thin a texture as often to allow the unclei-
lymg Meibomian glands to be rec oguised as so
many veitical markings It is quite common
for a few tiny elevations to he at the cornels of
the upper tarsal conjunctiva Deeply -seated
vessels may be seen shining through the loose
superior retio-taisal lolds " Follii les " are fre-
quently to be distinguished, and the lobules ot
the infeiior lacrymal (or palpebial) gland can
always be found embedded in the outer part of
the iolds It is most important to study the
chaiacteis of the noimal COIIJUIK tiva attentively,
foi a want of that knowledge is likely to lead to
errors both of diagnosis and of tieatmeut
1 CHRONIC MUCO-PUUULRNT CONJUNCHMTIS
— This affection lesults in most cases from a
neglected acute catarrh Its subjective symptoms
include heaviness and dryness of the eyes at
night, frequent blinking, and sensations like
those of foreign substances in the eye Indeed,
they are often like those of an unconocted enor
of refraction The palpebral conjunctiva may
be unduly ted , secretion m.iy be present aitci
sleep; and a common appearance is that of a
whitish, frothy spume collected m the corners
of the eye The patients frequently complain
of colours around artificial lights, the result of
particles of mucus on the cornea Complica-
tions— as, for example, troublesome lacrymation,
blepharitis, and ulcerative keratitis -are more
common m elderly subjects
Treatment — Wind, smoke, dust, or impure
air must bo avoided Errors of lefraction or
muscular anomalies should be corrected with
suitable glasses The lacrymal passages and
the nose must be carefully examined Weak
solutions of silver mtiate (gr £-1 to the ounce)
often render yeoman service, although they
must not be employed for too long, owing to
the risks of staining the conjunctiva Other
useful local astringents aic zinc sulphate (gr
1-2), alum (gi 2), bone acid (gr 10) In
many tases it is advisable to add to the fore-
going lotions a little tincture of opium A
remedy in much favour is the yellow lotion1
of the Austrian Pharmacopoeia, dioppcd into
the eye twice or thrice a day In children by
far the best remedy is the familiar yellow oxide
of meicuiy ointment (gr 10-20) An ointment
oi roppei sulphate, containing ^ to 2 gr of the
prpcipilated salt to half an ounce of soft paraffin
and an equal amount of hydrous wool fat, is
often efhc acious. In dimcult cases the everted
conjunctiva may be touched occasionally \vith
solid alum or bluestonc*
2 FOLLIOUIAH CONJUNCTIVITIS — The symp-
toms ot this auYction i osemblc those of chionic
muco-puiulent conjunctivitis, but m addition
the " follicles " aie unusually prominent These
are loundcd or oval, seldom exceed 1 5 mm m
diameter, aie more or less tianspaient, and are
generally arranged in rows " like the beads ot a
lOHary " The conjunctiva is laicly deeply in-
volved, and the changes are always more marked
in the lower lids than elscwheic The condition
is nevei associated with consecutive conical
changes Its pi c'disposmg cause appears to lie
m the adenoid tendency of ceitam subjects , its
exciting cause may be either geneial, as in-
samtaiy siirioundings, oi local, as an attack of
<icutc ophthalmia, the prolonged use of atropine
or phvsostigmine, a.id so on The best name
for this vvidely-spioad condition seems to be
wnjdefollicitliti*
Treatment — It the "iollicles" give rise to no
symptom, and aio not associated with discharge
from the eye, they aie best left alone Other-
wise, the same remedies may Ix? employed as
described in the last sec turn Tannate of lead
ointment (10 per cent) often acts well If the
oveigiowths be laige, theie can bo no oh]cction
to getting rid of them by squee/mg, cutting, or
other suigical means A change of air is some-
times beneficial.
3 TRACHOMA — This impoitant affection is
found almost exclusively amongst the poorest
cLisses, and in schools attended by those classes
It may cling to a particular building for years,
simply because pioper steps aic not taken to
1 The yellow lotion contains ammonium chloride, 0 5,
and 7inc sulphate, 1 25 parts, dissohed in 200 parts of
distilled water To that solution is added a mixture ot
absolute alcohol 20 parts, tamphoi 0 4, and saffron 0 1
The two solutions are mixed, allowed to stand for twenty-
four hours, and filtered
14
210
CONJUNCTIVA, DISEASES OF
eradicate it Certain races — as Russians, Poleb,
Armenians, Jews, and Irish — are peculiarly sub-
ject to the dmease, probably because their mode
of life favours the spread of infection Negroes,
curiously enough, are said to be practically
exempt In some countries, as Switzerland,
trachoma is almost unknown, in others, as
Belgium, it is widely spread. It arises only
by infection, but we know nothing definite as
regards the pathogenic agent, thought by some
to bo a micio-orgamsm, and by others to be a
proto/oon This much, however, is certain —
that infection is fosteied by a gregarious hie,
by bad ventilation, by lack of cleanliness, by
defective washing arrangements, and by the
absence of isolation for those affected Indeed,
the clinical evidence of the transmissibility of
trachoma is overwhelming IJoth eyes are
usually affected sooner or latei
Symptoms — Trachoma is essentially a chronic
ailment, subject (particularly in the earlier
stages) to acute or subacute exacerbations To
begin with, it affects the palpebial conjunctiva,
but, later, may spread to the cornea Its lead-
ing features aio — first, the development of
"sago-grain" bodies in the conjunctiva and,
secondly, thickening of the palpubral mucous
membrane The "sago-giam body," \\hich is
almost essential to diagnosis, appears to be a
"follicle," altered us the result of specific in-
vasion, presumably by a nucio-paiasite It is a
round, opaque, greyish - white growth, deeply
embedded in the hypeitrophied conjunctiva,
especially of the upper cul-de-sac Micro-
scopically, it consists of grouped lymphocytes,
supported by a delicate stroma, and often more
or less distinctly encapsulated According to
some recent researches, it may originate in the
lymph-vessels or spaces of the conjunctiva
Discharge, except in acute cases, is seldom
abundant An almost constant sign of trachoma
is ptosis, which gives the patient a sleepy look
The cornea may suffer in two ways, namely, by
the development of pannus or of ulceration A
well-marked paunus gives a chatactenstic ap-
pearance to the uppei third or so of the mem-
brane. The affected parts are n regular and
cloudy, and few or many enlarged vessels (con-
tinuous with those of the conjunctiva) branch
out into the web In bad cases the entire
cornea may suffer, and vision be reduced to
bare perception of light Indolent ulccration is
not uncommon along the free edge of a pannus
The usual explanation of the origin of pannus
assumes that it is due to the initiation of a
rough and thickened upper lip This theory,
novel thelcss, is hardly borne out by the known
facts Without entering into contentious points,
it may be safely asseitcd that pannus ropiesents
an actual tiachoma of the cornea, brought about
either by direct inoculation from the affected
lid, or else by the metastasis of infective particles
through vessels 01 lymphatics. Ulcerations of
the cornea simply mean disintegration of the
diseased material The sequels of trachoma
include scarring of the palpebral conjunctiva
shortening of the culs-de-sac, trichiasis, en
tropion, and imperfect sight as the lesult ol
corneal blemishes
Treatment — 2£i>i/uirotic, surf/teal, and accewoii
mean? are used For general use, the besl
eschtirotic is solid bluestone, rubbed over the
exposed palpebral conjunctiva once a day The
application may be continued for years without
harm Where inflammatory symptoms an
marked, 2 pei cent solution of silver nitrate
suits admirably, but it should be replaced bj
bluestone as soon as possible Other escharotict
are- -corrosive sublimate solution (1 to 4 pei
cent), solid lapis divinus, and undiluted carbolic
acid Op&ative meaxuie* are to be adoptee
under the following circumstances — (1) Wher
large masses of granulations are present, (2
\v hen the coniea is affected , (3) when loca
treatment hat* been tried for several months
without success , (4) when a patient is unlikclj
to submit to a prolonged course of escharotu
treatment, (5) when one eye is alone m\ol\od
The various operations include expiession, pai
tial renunal of the nppci retro-taisal folds, aiu
scrubbing the palpobral conjunctiva with <
tooth-brush dipped in some antiseptic lotion
The chief accetsoiy measure* are the use of sucl
lotions as pieviously mentioned, and the treat
ment of coineal liberations
PllLYl 'I LNULAlt CoXJUKt TIVll Ls
This condition is common in weakly c Inldrei
of the poorer (lasses, and frequently develop
aftei measles 01 other zymotic disease li
many cases it is dependent on "sciofula" o
"tubercle" Bach believes that it is set u]
by pyogenic microbes, paiticulaily the staph}lc
coccus pyogenes ameus He h,is succeeded b1
inoculation in producing the same affection, no
only in labbits, but also in human beings It
chiet impoitance is derived fiom the fact that i
is often associated with a similai affection of th
eoinca It is extremely prone to relapse, unlcs
its cause ean be made out and icmedicd Kme
has suggested that it should bo tcrmd "cczt
matous " when it coexists with eczema in othe
parts of the body, but that when such is not th
case the neutral term " phlyctenular " should b
ictamed
fymptom* — One 01 moic small pimples appca
upon the sclero-corneal junction, and a tnauguln
leash of vessels, having its apex at the aftecte
spot, is generally present The little nodul
speedily loses its epithelium, becomes converte
into a superficial ulcer, and then heals con
pletely It may, however, resorb without a
any time ulcciating When phlyctcnuloo he i
the ocular conjunctiva, at some distance from th
hmbus, they are usually large and acconipamo
by muco-purulent secretion In childieu ther
CONJUNCTIVA, DISEASES OF
211
are several atypical forms of phlyctenular disease
that need not be dcscril>ed more paiticularly
Treatment — Improve the general health by
good food, fresh air, cleanliness, outdoor exer-
cise, plenty of sleep, and (whenever possible) by
residence at the seaside or in the country Cod-
liver oil, best given as an emulsion, is of special
value, and tonics, as Parnsh's syrup and the
syrup of ferrous iodide, are useful The use of
these remedies should generally be preceded by
a short course of mercury, best given as Hydi
c crct , gr 1 , pulv rhei, gr 1 , sodn bicarb ,
gr 2, one powder every night for a week
Locally, calomel1 may be sprinkled over the
injected parts once or twice a day, or the same
lemedy may be given for home use as an oint-
ment containing 20 grains to the ounce Yellow
ointment (gr 1 0 to the ounce) suits many cases,
and may be used for month? together where
there is a marked tendency to relapse Should
photophobia be piomment, atropmo or cocaine
may bo combined \\ith the mercunal pieparation
SPRING CATARRH — This rare form of disease
is important from its liability to be confused
with trachoma Its signs and symptoms, how-
ever, <ire quite chaiactcnstic It is marked by
firm greyish elevations in the limbus, as well as
by a pale condition of the palpebial conjunctiva,
winch is so closely beset by enlarged papilla) as
almost to recall the appearance of a cobble
pavement The palpebial conjunctiva looks as
though it were coated with a thin layer of milk
(Vetsch) The patient complains of great irri-
tability of the eyes of a distinctly seasonable
type The irritation begins in spring or early
summer, and, after subsiding more or less com-
pletely dining the winter, returns during the
following spring Spung catarrh usually affects
both eyes, although not necessarily to the same
degiee It is met with mainly in young persons,
and may peisist for many years Nothing
definite is known as to its pathology
Treatment — Lotions containing boric acid,
sulphate of zinc, 01 antipyime are useful Oint-
ments of saluylic acid or corrosive sublimate
(gr 1-2 to the ounce oi lanolmo- vaseline), or of
amrnoinated mercury (2 per cent), may be em-
ployed In some cases douches of hot watci
appear to give temporary lehef If photophobia
exist, the eyes should be protected with goggles
Suigical measuies have been recommended, but
aie not in favour with most ophthalmic surgeons
Arsenic may be given inteiiially For my own
part, I have seen moio benefit from change of
air than from any other means, local or general
EXANl'lIKMATOUS CONJUNCTIVITIS — By this
name we mean any inflammation of the con-
junctiva associated with or closely following an
exauthem Measles often gives rise to such a
1 Preparations containing iodine must be avoided if calo-
mel is being applied, beciuse there is a danger of damaging
the conjunctiva if the two come into combination under the
form of mercuric iodide
condition, which is characterised by its tendency
to relapse and its rebelliousness to treatment
It takes the form, as a rule, of a catarrhal
ophthalmia, with a coincident eruption of phlyc-
tonulee and blepharitis, photophobia is a
common feature In addition to this, mam
outbreaks of measles are ushered in by con-
junctival inflammation During an attack of
smallpox, pustules may develop upon the con-
junctiva or cornea, and in the latter position
may entail serious results I have occasionally
observed small pustules upon the conjunctiva
and intcrmaiginal space during varicella Apart
from acute exanthemata, certain chronic inflam-
mations of the skin may be complicated with
conjunctivitis In acne rosacea a small nodule
m.iy form in the hmbus, and be accompanied
by localised redness and by photophobia After
pei sitting for several days the inflammatory
signs disappear, but a clear, bleb-like spot may
remain indefinitely The conjunctiva may be
accidentally inoculated with the vaccine virus,
although such a result is commoner upon the
edge of the eyelids In a case reported by
Cargill, firm, pale, flat swellings in the ocular
conjunctiva were found with a peisistent form
of urticaria , they were noticed to vary in si/o
from day to da} Charactci istic conjunctival
changes are present in leprosy Lastly, eczema
of the skin or scalp often coexists with phlyc-
tenular affections of the conjunctiva, altogether
apart from the pus inoculations mentioned upon
an earlier page
TUBKKCULOSIb
Tubercle of the conjunctiva is met with clini-
cally under several distinct forms It is often
primary — not associated, as far as one can tell,
with tubercle in other parts of the body, — and in
that event is almost certainly the outcome of an
external infection This tare affection runs a
lingering conxsc, is usually limited to a single
eye, and seldom attacks subjects over twenty
yeais of age It may 01 may not coexist with
lupus ot the face or elsewhere The foi m most
commonly recognised is characterised by the
development in the conjunctiva of small yellow-
ish nodules, or of bleeding cockcomb-hke gianu-
lations, which sooner 01 latei ulcerate The
nodules may be found in any part of the con-
junctiva, but the flattened granulations are
often confined to that of the lids The resulting
ulcers have ragged edges, grey nodular bottoms,
and are often more or less hidden by pus 01
debris The eyelids become swollen, heavy, and
unsightly , the conjunctiva throws off a muco-
purulent secretion , pain or discomfort appears
to be more often absent than present In
advanced cases the cornea may become involved
Erosion of the eyelids may occur, and adhesions
between the ocular and the palpebral conjunctiva
have been seen The neighbouring lymphatic
glands are practically always enlarged and
212
CONJUNCTIVA, DISEASES OF
tender. In another form the disease appears
under the guise of a pedunculated tumour,
attached by its pedicle to some portion of the
palpebral conjunctiva It resembles a papilloma
more than anything else
Diagnose — The diagnosis turns upon the
discovery of the tubeicle bacillus in the dis-
charge or pieces of the diseased conjunctiva
In obscure cases inoculation experiments 01 the
tuberculin test prove useful
Treatment — An attempt must be made to
extirpate the whole of the granulations, as by
excision, scraping, or the use of the galvano-
euutery , aftoi the operation, lodoform should
be applied locally Recurrences should be
watched for, and when found, promptly
attacked Internally, creasote and cod -liver
oil, separately or combined, appeal to bo of
service Careful attention must always l>e
paid to the sanitary environment of the patient
SYPHILIS
The initial lesion, 01 chancre, IH now and
again observed upon some part of the con-
junctiva, especially in children It foims a
round or oval ulcer, the edges of which aie
usually raised , induration may or may not be
present The coi responding pteauncular and
angulai glands speedily become involved
Treatment — The affected mucous membianc
should be washed, mtiht and morning, with
Lot hydr mgra (B P ), and aftci that the
soie dusted with powdered lodoform As soon
as the diagnosis is made, general treatment
by small doses of mcrcuiy should be begun
Several instances have lately been leported oi
a cunous infiltration of the ondar conjunctiva
coming on during the secondary stage of
syphilis, rendering the conjunctiva swollen
and semi - translucent Treatment — Meicury
internally and black wash locally Mucous
patches have been observed by several \vnters
Gummnta arc occasionally found in the ocular
conjunctiva, and ulcers may be produced by
their disintegration
Ophthalmia Nwfoui — This rare affection is
due to the penetiation into the eye of the hairs
of certain kinds of caterpillars (Bombyx 2>tm
and rubi) It is characterised by many small,
hard, greyish growths not only in the lowoi
part of the conjunctiva and solera, but also in
the iris and other parts of the eye Inflamma-
tory symptoms may attain a high grade A
history may be got of a caterpillar having been
thrown against the eye , or the patient, by the
nature of his occupation, may have been liable
to an injury of that kind Diagnosis will be
rendered certain by excising a nodule for
microscopic examination, when it will be found
to consist of round and of giant cells, together
with a hair Treatment — The nodules should
be removed, and inflammatory symptoms com-
bated by sedative and antiseptic lotions.
DEGENERATIONS
Conjunctive? — Xerosis occurs under
two forms— the epithelial and the parenchy-
matous. Epithelial xerosis is a superficial
change of the ocular conjunctiva, limited parts
of which become dry and lustreless, and are
covered with a foam -like, whitish substance,
containing the xerosis bacillus in large numbers
The changes ate specially prone to affect the
temporal side of the ocular conjunctiva, and
often take a triangular or oval foim The
spots appear slightly raised, and (when magni-
fied) give one the impression of being made up
of so many minute globules of mercury They
may be readily wiped away, as with wool, but
are reproduced \\ithm 24 or 36 hours The
neighbouring conjunctiva may be peimcated
with dilated vessels, and be thrown into small
folds conccntnc with the edge of the] cornea
when the eye is moved This form of xerosis
affects mainly thin, poorly-nourished chilchen,
who not infrequently suiter Irom otorrhoea It
makes its appearance in spring or summer, and
may iccui yeai after yeai at that period with-
out entailing any sciious mischief It may or
may not be associated with definite night-blind-
ness It has been shown by the wnter to
coexist with several other conditions (1) a
deficiency in hemoglobin , (2) alteiations in the
visual fields foi giecn and led , and (3) an ex-
aggeration of the fund us reflexes visible \vith
the ophthalmoscope in most young ejes We
assume that epithelial \eiosis is the outcome,
remotely of lowered nutrition, and immediately
of dazzling by bright light Treatment —The
most important remedy is iron, best given in
the well-known foim of Bland 's pill
Parenchymatous Xerow -—This much more
serious malady commonly ionns part of some
general ailment, the exact naturo of which is
not well understood In this countiy it is
found only in young children, who show, be-
sides frothy conjunctival patches, night-blmd-
ncss and cloudy cornea? The comeal changes
usually go on to perforation, and the patients
nearly always die This malady is generally
bilateral, and the usual signs of irritation, such
as redness of the eye and photophobia, are often
conspicuous by their absence, indeed, the
lacrytnal secretion may bo wholly suppressed.
As causes, hereditary syphilis, insufficient or
badly -selected food, and prolonged diarrhoea
or vomiting, have been mentioned Among
natives in India Herbert found mucous mem-
branes other than the conjunctiva involved —
for example, those of the mouth, nose, larynx,
bronchi, intestine, and bladder Treatment —
The eyes should be cleansed with sublimate
(1 . 5000) and covered with pads steeped in the
same solution. Physostigmme sulphate, gr 1 ,
cocaine hydrochloride, gr 4, distilled water,
1 ounce, may bo dropped into the eyes two or
Ptilyt't«Bwt*f conjunct « UK
Acute Ophthalmia.
DISEASES OF CONJUNCTIVA
CONJUNCTIVA, DISEASES OF
213
three times a day However, more success is
to be looked for from the employment of
general than of local measures
Pemphigus — The conjunctiva is occasionally
affected by pemphigus, which may or may not
be associated with a, similar disease of the skin
or of other mucous membranes, especially those
of the lips, nose, mouth, and fauces Fiom
time to time bullee make their appeal ance upon
the conjunctiva, which becomes, at first, thick
and red, and, later, undergoes cicatrici.il con-
traction It is raie, howevei, to sec the actual
blebs, because they aic so delicate as to inpture
speedily In this way the conjunctival sinuses
are shortened or altogether obhteiated, tnchiasis
or ontropion is set up, and the lids become ad-
herent to one another or to the globe of the
eye The coruoal epithelium also HU tiers, be-
coming dull and dry, like the eye of a dead
fish. To this advanced condition the name
"essential phthism" or "essential atrophy of
the conjunctiva" has long been applied The
condition is essentially clnonic As a uile, the
prognosis is bad, although a few cases seem to
rccovei According to modem researches,
pemphigus is duo to .1 diplococcus, different
from any of the ordinary pjococci, and capable
of cultivation upon various media outside the
human body Tin* acute foim of the disease
attacks butcheis with dispioportionato fre-
quency (Pel net) It seems likely that the
conjunctival affection m.iy arise m one of
thieo ways (1) AS a primary disease resulting
from cctogenous inoculation , (2) as an ex-
tension, through the laciymal passages, trom
pemphigus oi the mouth 01 nose , and (3) by
conveyance of the specific miciobc by the
patient's finger from cutaneous bull* Ttent-
ment -The treatment is purely palliative
Arsenic may be administered internally, and
the conjunctiva kept clean and supple with
ointments containing corrosne sublimate (gr J),
lodofoim (gi 5), or bone acid (gi 60) Boro-
glycende has also been employed Attempts
to remedy the condition by tiansplantation oi
mucous membrane from other patts of the
body have so far not yielded veiy encouraging
lesnlts
Laidacevui Degeneration — This rare disease
has been observed chiefly by Russian surgeons
It is marked by a progiessivo, non-inflammatory
hypei trophy, commencing in the retio-tarsal
folds or plica semilunaris, and slowly spreading
to othoi paits of the conjunctiva The affected
mucous membiano is of jwile colour, resembles
m appearance bacon -fat, and does not bleed
when incised It is said to attack adults, who
may or may not have suffered from trachoma,
and to occur independently of degeneration
elsewhere, as in the liver, spleen, or kidneys
Treatment — Excision, partial or complete, is
recommended by those who have had experi-
ence of the disease
Conjunctivitis Peti t ficaw — Under this name
Lebor has described a peculiar affection of the
conjunctiva, which becomes chronically in-
flamed and bestrewn with white, opaque dots
The chalky-white colour of the deposits con-
tiasts with the redness of tlwnnucous moinbrane
in which they lie They gradually get larger,
so that the parts involved finally look almost as
though they had been petrified Lcber found
the deposits to consist of an organic combina-
tion oi chalk. It is noteworthy that in Leber's
case the disease led to partial symblepharou,
and that the mucous membrane of the tongue
showed epithelial changes
VARIOUS CONDITIONS
Pttryqium — A condition of tho ocular con-
junctiva, a fold of which assumes a triangular
foim, and becomes firmly adherent to the
superficial layers of the cornea The tine
ptcrygium occurs only on the innei or outer
side of the coinea m the region corresponding
to the palpebral fissure A false ptorygium,
however, may be met with in other positions
At first, when the pterygium is growing, it is
thick and fleshy ami marked by obvious vessels,
like the wing of an insect, later, it becomes
thin and pale and almost of ticatncial appear-
ance Its course is essentially chroma. During
the progiessive stage, it gives an unsightly look
to tho eye, may mechanically limit the ocular
movements, and may cnctoach on the visual
part of the cornea The condition, which is
lare in women, is met with chiefly m middle-
aged men It specially affects those who have
lived abroad, and is rathei common in sailois,
piobably because they are exposed to vicissi-
tudes of \\eathei Theotiei — Ailt assumes
that noxious influence, such as dust, causes the
epithelium of the conjunctiva and coinea to be
shed, so that a little supei added swelling makes
those two structuies to adheie and a point 01
tag of conjunctiva to become fastened to the
coinea Fuchs believes that it originates fiom
a pinguecula which has gradually made its way
into the coinea, and m so doing drawn a fold
of conjunctiva with it A kind of spurious
ptciygium may now and then follow acute
ophthalmia, burns, or scalds Treatment — If
the condition be stationary, and have not en-
croached senously on the cornea, it is best left
alone, but otherwise an operation must be per-
formed Tho pteiygium is carefully dissected
away from the coinea, and, its ajwx being folded
upon itself, is retained undei the ocular con-
junctiva by a suture The conjunctival wound
must be closed as neatly as possible by means
of a continuous silk thiead The cornea, it
must bo remembeied, always remains cloudy at
the spot where the ptcrygium was attached.
Symllepharon — This condition is marked by
one or several adhesions between the ocular and
the palpebral conjunctiva. It is caused by any-
214
CONJUNCTIVA, DISEASES OF
thing that produces an ulceration of the opposed
surfaces, eg burns, the action of lime, certain
forms of acute ophthalmia, tubercle, pemphigus,
and operations on the conjunctiva It affects
the lower more frequently than the upper lid
Different names have been applied according to
its position, as symblcpharon postering and an-
tenus. The foimer indicates that the union
has involved the conjunctival formces; the
latter that those structures have remained free
Symblepharon totalc means that the eyelids arc
adherent to the eyeball. Symblepharon, when
maiked, may cause disfigurement, irritability of
the eye, limitation of the natural movements,
or (rarely) interference with sight Treatment
— Many operations, home of a highly ingenious
charactei, have been devised. The simplest
plan is to separate the lid from the eyeball by
dissection, and then to cover the raw places
with morsels of mucous membrane taken from
the mouth. Another way is to make liberating
incisions in the neighbouring conjunctiva, so
that the edges of the wound m the ocular con-
junctiva may be brought together with sutures
The treatment of symblepharon postcrms is not
so satisfactory
Pinffuecula — I'mguecula, like ptcrygmm, is
seldom seen save in elderly persons It takes
the form of a small yellowish elevation of tri-
angular shape, situated in the ocular conjunctiva,
usually on each side of the cornea The turnout
consists of dense connective tishiie (which has
undergone a hyaline change) covered with
thickened epithelium Treatment — Removal,
if called for
Effusions into the Conjunctiva — So loose is
the texture of the oculai conjunctiva that
effusions of blood or serum readily occur into
its substance In extensive haemorrhages almost
the entire ocular conjunctiva may be involved,
and blood may even pass for some little distance
beneath the epithelial layer of the cornea It
is not uncommon after squint operations for
the iris to appear changed in colour, owing
to a transudation of extravasated blood into
the cornea The subconjunctival hiemoiihage
becomes slowly absorbed. Its mam causes aie
two in number (1) fragility of the blood-
vessels, (2) mjur}, opciation, strain, or inflam-
mation Ti en tment — Compresses of lead lotion
Chemosis, or distension of the conjunctiva by
blood serum, may accompany severe inflamma-
tions not only of the conjunctiva, but also of
other parts of the eye or of its surroundings
It is, therefore, merely a symptom In a
marked case the coniea is overlapped by the
swollen mucous membrane, which also protrudes
from between the eyelids. Another kind of
chemosis, thought to be of non-inflammatory
origin, is sometimes observed in elderly persons
Some of the patients suffer from chronic Bright's
disease, but, as a rule, the cause of the oedema
is obscure Holmes Spicer has recently described
a form of chemosis, which he considers due
to " obstruction of the lymph streams " The
patients give a history of acute rheumatism,
and the conjunctival affection is associated with
lacunar tonsillitis, glandular enlargement, and
febrile movement Lastly, chemosis has been
noted by Swan M Burnct after the internal
administration of quinine.
Staining of the Conjunctiva — The conjunctiva
may be stained by several agents, such as silver
nitiate, protargol, largin, and iron sulphate
Lead acetate may lead to local ulceration and
to deposition of the salt
Lithians o/ tlie Conjunctiva — In gouty sub-
jects deposits of uric acid may sometimes be
found in the palpcbral conjunctiva Should
they cause irritation they may be removed
Small yellowish concretions are quite fiequently
found m the palpebral conjunctiva of young
pei sons Accoidmg to Fuehs, these are to be
looked upon as tubular glands of new formation
containing fungi (pilzrawit)
Conjitnitivttw porn Dazzhny -A form of
paiuiul ophthalmia may quickly follow exposure
to snow, clectnc light, or the X-rays It is to
bo treated by cold applications to the lids, and
by dropping a 2 per cent solution of cocaine
into the conjunctival sac at intervals It
speedily gets well
Emjihyaema — This implies a communication
between the subconjunctival tissue and the
nasal cavity or air-sinuses about the orbit
Traumatism is the usual cause On palpation,
characteristic crepitation can be elicited Treat-
ment — Compressivc bandage for a few houis
TUMOUKS OF THK CONJUNCTIVA
Besides the tumours already mentioned the
following new growths have been found in the
conjunctiva cysts, parasitic and otherwise,
myxoma, papillonm, fihioma, polypi, epithehoma,
sarcoma, and carcinoma The treatment is to
letnove the tumour with the least possible
disturbance of the neighbouring parts A
simple puncture, however, may sometimes
suffice, its when dealing with the so-called
" simple cyst " In the case of malignant
growths (which generally originate from the
limbus) it may be advisable to cauterise the
spot of origin.
INTUKIKS ot IHK CONJUNCT A
The conjunctiva may be injured as the result
of direct violence or the action of chemical
agents The degree of inflammation is often
out of all proportion to the size of the irntant
Mechanical injuries, doubtless, quickly become
complicated with pathogenic organisms, from
which the conjunctival sac is seldom free.
Moreovei, microbes may have been introduced
upon the surface of foreign bodies or m other
ways. Injuries from lime deserve special
mention They are very formidable when
CONJUNCTIVA, DISEASES OF
215
caused by quicklime, which has a double action,
namely, that of heat evolved by contact with
the tears and that of chemical irritation When
due to slaked hmo, which is moie commonly the
case, they are less disastrous* Treatment — In
bevore cases it IH necessary to place the patient
under the influence of an anajsthetic, and, after
removing every particle of foreign mattei, to
apply castor oil to the injured mucous mem-
brane Prognosis will always be grave, owing
to such secondary results as implication of the
cornea, hypopyon, entropiou, and symblcpharon
Uncomplicated wounds of the conjunctiva heal
kindly enough if first made aseptic, and then
drawn together by fine bilk sutures It is said
that the staining left by giains of gunpowder
may be got rid of by electrolysis
Conjunctivitis.— Inflammation of the
conjunctiva,! ruinous membrane, blenuorrhagic,
gonorrhea!, croupous, diphtheritic, cczcmatous,
follicular, granular, purulent, membranous, etc
See ADRENAL GLANDS (Adrenalin, Hay Feiw) ,
CONJUNCTIVA, DISEASES OP, CORNEA (Phlytteini-
lar Ulcer m Eczematoii* Conjunctivitis), (JOLT
(Eye) , MEASLES (Complication*, Conjunctiviti*),
MENINGITIS, EPIDEMIC CRREBRO-SPINAL (Symp-
toms, Special Ntn\es, Eye*) , NERVES, MULTIPLE
PfcRiPHhRAL Njiuiims (At teincal Neuritis, tfymp-
torni) , RHEUMATISM, ACUTE (Symptom* and
Course, Conjumtiviti*) , SCLEROTIC, DISEASES OK
(tiubconjunitiviti* 01 Epiiclei iti*) , SMALLPOX
(Symptom*, Eiuptive Staqe) , TnuioiD GIAND,
MEDICAL (ExophthtiJmo*, Conjunctiviti*) , TYPH-
OID FEVER (Ocufat Complication*) , URETHRA,
DISEASES (Cownikwa, Complication*)
Connective Tissues. Me PHYSIO-
LOGY, TISSUES (Connective, Mucoid, Fibroin,
Cartilaye, and Bone)
Consanguinity. — Blood - relationship
as opposed to marriage-relationship (affinity) ,
of the same blood There is a widespread belief
that marriages of consanguinity piedispose to
various diseases (albinism, chorea, deaf-mutism,
epilepsy, goitre, idiocy, haemophilia, retimtis
pigmentosa, rickets, and malformations) in the
offspring , this belief finds expression in the
proverb, " Heirathen in's Blut thut selten gut
sterben, verdciben, odor kemo Erben", but
there seems to be some doubt whether con-
sanguinity per se produces evil effects, whether
indeed it is not a bad family history intensified
by intermarriage that is to blame
Consciousness. »S'« BRAIN, AFFEC-
TIONS OF BLOOD - VESSELS (Anaemia, Ilcemor-
rhaffe, Embolism), HYSTERIA (Epileptic Peiiod),
INSANITY, ITS NATURE AND SYMPTOMS (Relation
of Mind and Brain, Biology of Consciousness) ,
INSANITY, NATURE (Delusional, Alternate Per-
sonality m Double Consciousness) , MEMORY IN
HEALTH AND DISEASE (Physical Basis of Afemory) ,
UNCONSCIOUSNESS
Consensual.— -Reflex actions brought
about by sensory impressions without the in-
tervention of the cerebrum itself and its dis-
criminating will
Consent. /S'ee MEDICINE, FORENSIC (Rape)
Conservancy System.— A system
of sewage, now generally condemned, by which
slop water was got nd of by the drains, while
solid excrement was disposed of by means of
privies or earth closets, tiee SEWAGE AND
DRAIN Abb (tiy*tems)
Conserves. He? CONNECTIONS, PRE-
SCRIBING
ConSOmm£. — A strong broth or soup,
for the making of which meat, vegetables, bone,
and connective tissue are needed , it forms a
jelly when cold »Vee IN\ALID FEEDING (General
Pttpatation of Meat*, Koup-Ma1nn<j)
Consonants. See NOSE, EXAMINATION
OF (Cfuiraftei of t/te Voice), PHYSIOLOGY, RE-
SPIRATION (Voice, Consonant Mounds) , STAMMER-
ING
ConsternatlO.— Pavor nocturnus (night
tenor) in children , 01 (in other cases) stupor.
Constipation.
Pm SIOTOMCAL CONSIDERATIONS
CAUSES
S^MI'IOMS
TRFVIMfcNF
215
216
217
217
Xce aUo ABDOMINAL AM^UIUSM (Symptoms,
Prepare) , BRAIN, AM-ECIIONH OF Bi OOD-VESHELS
(Paialyws from V<t \culai Lesion*), BRONCHITIS,
ACUTE (Etiology, Prednpovny Cau*e») , TLIMAC-
TERIC INSANITY (Titatment of Constipation in) ,
COLON', DISEASES or (Mnliynanl) t UASiRo-lNfEs-
IINAL DISORDERS OF INFANCY (Con*tipation) ,
(»OUT (Alimentary tiy*tem) , HYDROPATHY (Con-
stipation), INSANHY, Eiioio(.\ {)» (Direct Cawws,
tiymjHitfutH, Infinity), LUNGS, EMPHYSEMA
(Causes), MENINGITIS, TUBERCULOUS (Symptoms),
MMASIS (Inte*tinal) , PALPITATION, PHARMA-
TOLOGY , PREGNANCY, PH\HIOIX)GY (Local
Clvanye*) , PREGNANr\, AFFECTIONS AND COM-
PLICATIONS (Dige*tive tiy*tem) , PURGATIVES ,
RECTUM, DISEASES (Ptmistent Constipation),
TFTAK\ (Causation), THERAPEUTICS, HEALTH
RESORTS (tiea*ide Constipation), ToxicoiX)GY
(Lead), TRADES, DANGEROUS (Lead-Poisoning) ,
VICE (Alimentary System)
PHYSIOLOGICAL CONSIDERATIONS — While the
frequency with which the excreta of the bowels
are expelled varies at different ages, it may be
accepted as practically normal that from later
childhood onwards an evacuation at least once
216
CONSTIPATION
daily should occur It is true that in the case
of many, especially of the female sex, defalcation
occurs much less frequently — once in three or
four days, or even seldoiner, but while it has
to be admitted that many of such cases present
apparently few or none of the symptoms of faecal
retention, yet none the less such a condition of
the excretory functions can hardly be looked on
as normal
The intestinal contents, which in the small
bowel are in a very fluid condition, undergo a
marked absorption during their passage thiough
the large intestine Hence it is only in the
lattei part of the colon that they assume the
characteiistic semi-solid appearance of a natiual
motion, and in the sigmoid flexure the freccs aio
stored until the act of defecation takes place
The incitement to this is usually the passage
into the rectum (as a result of peiistalsis in the
sigmoid flexure) of part of the contents of the
latter. This is apparently frequently induced
by the entrance into the empty stomach of
food, especially when the sigmoid flexure
is moderately distended with excreta [An
exaggeration of this normal mechanism is seen
in what is known as henteric (lurrhou, wheie
the ingestion of a meal is at once followed l>y
a desire for evacuation as the result of the
entrance of a small quantity of fceoes into the
rectum from the merely pait tally loaded
sigmoid ]
Although the act is a reflex one earned out
through a centre in the spinal cord, it is largely
influenced by the w ill. In man this centre is
situated in the lumbar region of the cord The
presence of the accumulated forces in the
rectum causes, by reflex action thiough the
centie, relaxation of the sphmctei, while in-
creased intestinal peristalsis is also set up In
voluntary defalcation the act is started by a
full inspiration, closuie of the glottis and fixation
of the diaphragm, followed by con ti action of
the abdominal muscles and levator am, the
latter in this way exerting pressuie on the
rectum, while the tension of the pelvic fascia
and muscles of the pelvic floor offer the requited
resistance
Definition — Constipation may be defined as
a condition in which the alvine evacuation is
difficult and deficient either in amount 01
frequency, or both, \v ith a consequent tendency
to fcccal retention
While in reality largely a symptom present
in a great variety of conditions and not a
disease, constipation is frequently in itself of so
much importance as almost to warrant its being
regarded as such Ceitainly in view of the
groat frequency of its occurrence, the amount of
discomfort and suffering it produces, as well as
the benefici.il effects and satisfactory results of
its proper treatment, the condition is one which
calls for moie careful attention and less em-
pirical treatment than it often receives from
the practitioner (For constipation in children
see " Castro-Intestinal Disoiders ")
CAUSES — While the causes of constipation
are so numcious and varied that it is difficult to
summanse them, it is essential to the satis-
factory tieatment of any case that the real
source of the trouble be discovered AH a rule
seveial factors are at work, and these may
perhaps be best considered buefly undei two
heads — (A) Faulty expulsive mechanism , (B)
Faults in the intestinal contents
Faulty Expulsive Mechanism — In this first
group of causes one of the most important is
that of hnlit , carelessness in attending to the
call to stool, with the icsult that the bowel
becomes accustomed to the piescnce of focal
accumulations, and one of the chief stimuli to
legular dcftccatiou is thus lost In other cases
the sedentary habits or occupation of the patient,
w ith the consequent feebleness of the abdominal
muscles and sluggishness of the whole circula-
tion, constitute a powerful factoi
In anothei group of cases the souice IH to be
found in the bowel Apait from the existence
of actual constriction from malignant disease in
the bowel, the possibility of which must never
be lost sight of even in comparatively young
subjects, constipation may aiiso horn feebleness
of penstaltie force consequent on a lowering of
the nci vo-muscular tone of the bowel, e<j in old
age or an.i-mm, fiom cicatrisation of old ulccis,
fiom the picsemc of pciitomtis (subacute or
chiomc) or old-standing bands or adhesions
(impeding peiistaltus), from piessure on the
bowel by tumours or othei swellings of adjacent
paits, ey uteimc enlargements, physiological
or pathological, ovarian tumours, ett , while,
again, the o\cr- distension which may result
from such blocking of the lumen of the bowel
still furthci tends to puipetuatc the malady by
lessening the pcristalth foice In other in-
stances, especially oi painful pelvic disorders in
women, the diead of pain in defalcation and
actual pain itself may have an inhibitivc effect
on peristalsis, and the same is seen in cases of
heemoiihoidN, anal hssme, etc
On the other hand, the constipation may
at isc fiom an mteifeience with the nervous
mechanism concerned m controlling the act of
defecation, fiom involvement of the centics or
nerve-fibres, as in some foirns of spinal disease,
or as a part of various cerebral disorders, e </
melancholia, tubercular meningitis, rtc
Lastly, tnejficienry of tJte accessory muscular
tnerfumiwi may contribute to the production of
constipation, as in some cases of paralysis, or in
patients whose abdominal muscles have been
over-distended, eg by repeated pregnancies,
iiscites, etc , or, again, the presence of severe
cardiac or pulmonary disease may render any
straining efforts on the part of the patient
impossible
Faults in the Intestinal Contents —The solid
CONSTIPATION
217
as well as the liquid ingesta may be at fault, or,
on the other hand, the intestinal secretions may
be defective Thus the food taken may be too
soft and too easily absorbed, leaving little or no
residue, such a diet in many c ases having been
adopted because of dehcicnt masticating |x>wers
owing to loss of teeth Or the intestinal con-
tents may be too dry, cither fiom insufficiency
of liquids taken 01 deficiency in the intestinal
secretions Instances of this latter ait> seen in
oases of jaundice, diabetes, etc, 01 cases of
excessive perspiration (from cxeicise 01 disease),
bringing about increased loss of fluid from the
body In other instances the r/uahty of the
drinking watei is at fault , thus it may contain
an excessive amount of lime salts, 01 it may bo
contaminated, e </ w ith lead
SYMPTOMS — When constipation is merely one
of the manifestations of the presence of some
other malady (eq tubercular meningitis) its
symptoms are scarcely to be separated from
those attendant on the primary disease Hut
while it is undoubtedly ti ue that in many in-
stances of habitual constipation the patient
exhibits little in the way of symptoms, yet in
the majority of cases there arc found to be present
to a greater or less extent such manifestations
-as general languor, toipidity, and depression of
spirits, along with irritability, a feeling of fulness
in the head, passing into actual headache, furring
of the tongue, with foulness of bieath and loss
of appetite, together with some feeling of fulness
and distension in the abdomen, or even pain
Jn a few cases marked mental disturbance is
present Severer cases may be attended by
vomiting, hu cough, etc , the usual symptoms of
intestinal obstruction
The chaiacteristic stools in constipation con-
sist of small, diy, hard, often dark, and offensive
masses, along with \\huh, in cases of old stand-
ing, is occasionally to be found mucus, or even
blood, if sevt'ie httannng has been lequned foi
their expulsion
Lastly, it must never be forgotten th.it
thanhwa may bo really a symptom oi constipa-
tion, the accumulated ftecal masses by then
piescnco giving rise to catarrh in the lower pait
of the bowel, with consequent desire foi frequeat
evacuation In such cases it is often only on
digital examination of the lectum that the
existence of constipation is levealed, as shown
by the continued presence of scybalous masses
in the rectum in spite of frequent evacuations
In addition, what may be termed secondary
symptoms of constipation may anso, either
locally, e g prolapse of the bowel, haemorrhoids,
etc , or as the result of pressure on the sur-
rounding parts consequent on the loaded
condition of the bowel there may bo vcsical or
uterine catarrh , or, again, varicosity of the veins
of the leg (especially the left) may be mci eased,
if not actually set up
Before commencing treatment it is important,
in view of the difference of prognosis in the two
conditions, to decide if possible whether the case
be one of mere functional derangement or of
organic disease
TREATMENT — As has been already insisted
on, this must be rational, and adapted to the
paiticular causes at work in each case, and to
this end the relatively subordinate position of
<hu<j& in the treatment of the majonty of cases
should always be boine in mind The mere
i ou tine oidenng of some cathaitic remedy,
without further attempting to picvcnt the recur-
rence of the constipation, cannot be too strongly
condemned The enormous and increasing con-
sumption of innumerable patent medicines in-
dicates only too clearly the extent of the evil,
w huh is 1111 foi tunately too often only pcipotuatcd
by their injudicious employment The adnnn-
istiation of a vigorous cathartic, however, as a
commencement to the thorough treatment of a
case of constipation is often not only very
beneficial, but even essential , but it is always
advisable to explain fully to the patient the
geneial hygienic and dietetic management of the
condition before advising the employment of
medicinal remedies
Habit —This is one of the most impoitant
piophjlactic measuics in the treatment of con-
stipation The patient must be urged to go
to stool each day teyulaily at the same houtt
pieferably aftei a meal, but the time should be
chosen with a view lather to its being available
evety day foi this puipose Thus for those
whose business requires them to take breakfast
at varying houis — often with a huinod rush for
tiams, etc — the habit of going to stool at l»cd-
tnne should be lecouimendcd , similaily those
who suflei from severe anal troubles, and especi-
ally prolapse or piles, should be advised to choose
the same horn Not only will the patient be
likely to obtain then greatei facilities foi spong-
ing himself and letuimng the piotruded mass,
but the subsequent rest in bed allows of the
congestion subsiding before active exertion is
again called foi
It is of the utmost importance that this habit
of punctual daily evacuation of the bowels should
be insisted on fiom eaily childhood in both
sexes Too little attention is paid to this mattei,
especially in gnls, entailing much subsequent
annoyance, and even suffering Those who have
not acquiied this icgular habit must be encour-
aged to pciscveie in going regularly to stool at
a fixed hour, even although no motion may
icsult at first In some cases the adoption of
the inoi e "douching" attitude natural to
defecation in the open air — as by using a
chamber-pot — has been lecommended
Again, w ith many, smoking after a meal acts
decidedly as a laxative, but the all-important
point w i eyulanty and punctuality in the daily
evacuation
Diet — The patient's diet should always bo
218
CONSTIPATION
carefully inquired into. Foods made of the
coarser grams, or in the preparation of \vlnch
part at least of the more indigestible cellulose
and fibre is retained, should be substituted for
those of the finer soi t " Whole meal " porridge,
oatcakes, and brown bread are usually cosily
taken, and the patient should be encouraged to
eat the crust, and not merely the softer parts of
the bread Manypeople require syrup or treacle to
their porridge, and these also are useful laxatives
Vegetables, by reason of the large proportion
of cellulose and ncutial salts they contain, are
also very helpful, while the gases which some of
them are apt to evolve still further stimulate
intestinal peristalsis, though they may somewhat
increase the patient's flatulent distension Thus
raw tomatoes, salad, or merely fresh lettuce
should be recommended, and as a general inle
the various vegetables in season should enter
largely into the regular dietary
Similarly fruit, raw or cooked, should be
utilised freely An orange or a raw apple before
breakfast is an efficient laxative to many, and
the patient should bo advised to see that fruit
always forms a part of his daily dietaiy The
attraction which soft (non-laxative) milky foods
have for those whose teeth have failed them
mubt be counteracted by combining with these
such fruits as stewed figs or prunes, apricots,
etc, and if the fibies of these prove too tough
for the patient's imperfect teeth aitihcial ones
must be obtained Fruits in the foim of jams
also are of advantage, and marmalade possesses
marked laxative properties Milk and milky
foods should be sparingly used, and of these
latter the coaisei -grained varieties, eg sago or
whole rice, are preferable to such as arrowioot
and coinflom
Liquids — The importance of attending to the
question of the amount of liquid consumed by
the patient can hardly be overestimated Many
people, especially women, seldom take a drink of
water, tea — too often with a fairly htroug propoi-
tion of astnngcnt tannin in it — being almost then
only beverage A single tumblerful of water
taken on an empty stomach on rising — or, if
required, at bedtime also —will frequently, in
conjunction with the other general directions
mentioned, have the desired effect If the patient
perspires much he should be recommended to
drink water still more freely, especially between
meals Excessive "hardness" of the drinking
water from the presence of lime -salts must be
temedied by boiling the water and filtering, or
by the use of rain- water for cooking purposes
as well as dunking.
Coffee or cocoa is preferable to tea, contain-
ing less of the astringent tannin, and malt
liquors tend to be more laxative than spirituous
liquors Buttei milk may also be ordered as being
more laxative than ordinary milk
fijreruse — The frequency of constipation in
those of sedentary habits is well known, but the
mere ordering of exercise is not enough. Care
must be taken to see that the patient adopts
some form of exercise likely to have a beneficial
effect upon his abdominal muscles, and so on
the underlying intestines Thus nding on horse-
back, cycling, golfing, tennis, and swimming are
much more likely to benefit than meiely walk-
ing , while special gymnastic exercises calculated
to strengthen the abdominal muscles (often so
feeble in females) are of the utmost value
One precaution, however, must bo borne in
mind Should exercise, as in the case of some
delicate women with pelvic disoiders, give rise
to pain, the constipation will probably be lather
increased than diminished, the imtation inhibit-
ing penstalsis apparently reflexly through the
splauchuius In such cases even moderate
cxcreise may have to be prohibited, and (as
afterwards lefeired to) an opiate may be required
as a laxative
MasMtye, etc. — This is frequently of most
service in those cases in which the beneficial
forms of exercise cannot be camud out, viz the
elderly or the very young Especially useful
is regular systematic massage ot the colon in
the direction of peristalsis, earned out by the
patient himself or a trained attendant Others
have strongly recommended vibration as being
a more potent and less dangerous mode of
stimulating peristalsis in severe atonic cases
With this may be combined the use of cold
compi esses or cold douches to the abdomen,
while in some obstinate cases beneficial lesults
are obtained from the icgular use of electricity
to icstore tone to the intestinal walls as well as
the abdominal muscles For this, special forms
of electrical appaiatus have been devised
Medicinal Itemedtfv — Should the various
hygienic and dietetic measures above referred
to fail to effect a cuic of the condition, lecourse
must be had to mcdicin.il remedies, but only as
an adjuvant
The number of cathartic or laxative lemedies
is enormous , hcie only a few salient points will
be referred to
(a) Enemas — Where the constipation is of
long standing, with an accumulation of hard
seybalous masses in the rectum and sigmoid
flexure, these should be softened by enemas of
soapy water or olive oil and oxgall, while in
sevcrei cases it is sometimes necessary to break
down the masses and remove them by means
of a spoon handle, care being taken to see that
the accumulation is thus thoroughly removed
Should some scybalous masses be lodged higher
up in the intestine, large douches of warm water
inserted by means of a long tube connected with
a head of water should be persistently employed.
It is well to remember that some writers have
pointed out that, once this form of treatment has
been begun, there is a risk of auto-intoxication —
apparently from the liberation of toxmes from
the softened scybala — if the douches are not
CONSTIPATION
219
administered daily so long as any masses remain
in the bowel Again, as a stimulant to defecca-
tion small enemata of glycerine, or suppositories
of the same, prove very useful, the forms of the
latter now obtainable constituting one of the
most convenient and least mjmious therapeutic
remedies wo possess Especially convenient are
they for patients who are fioin home or duel-
ling , but the habit of employing thorn system-
atically » to be guarded against Occasionally
considerable benefit may be derived from the
use of smttll enemata of cold watei, which appear
to act by stimulating peristalsis
(ft) Drugs — All cathartic remedies which have
an attnngent tendency as pait of their after-
effects should be rigidly a\oided in treating
habitual constipation, e </ Gregory's powder
What should be aimed at in prescribing is to
give something which may so tone up the bowel
to act that the drug can be dispensed with in a
short time Especially important among these
intestinal tonics are cascara sagrada, mix vomica,
or strychnine, and aloes These may be given
together conveniently in pill form, a little bella-
donna being often added with 01 without hyo-
bcyamus to prevent griping 1 1 is most important
to impress on the patient that it is not a putija-
tivt pill he is getting, but a tonic for his intestines,
and therefore he is not to expect an ac tion of the
bowels as the result of one or t\\o pills Such a
pill as - 11 E\tr cascarie sagrada', gi iss , extr
nucis vomictc, gi \ , c\ti aloes, gi \ , cxtr
belladonna, gr J, t»\ti gent co q s , given
twice or thuce daily, always as an adjuvant to
the yeneial measuici stated pievtoutly, seldom
fails to bung about in a few da\s a icgularity
in the evacuations which continues after the
pills ha\o been qmdnally omitted In anemic
females the addition of a little 11011 in some
foim to the pill is often of great advantage
Again, the liquid form of cascara (with which
an equal amount of glycerine may lie advan-
tageously combined) is sometimes veiy effectual
if taken nightly foi some time to tone up the
intestine, always in addition to dietetic and
other general measures The patient should be
always stiongly warned against indulging m
occasional purgatives, and encouiaged to per-
severe in mcasuies calculated to bring about a
natural daily evacuation
Sometimes in plethoric subjects, or where the
motions are excessively diy, salines gi\en in the
morning act best, cither m the form of one of
the numerous aperient waters, eg Hunyadi
Janos, liubinat, etc , 01 as the simple salts, e g
Carlsbad, etc. , but while often beneficial for a
time, and especially useful in obstinate cases as
an alternative, e g during summer weather, they
are never of the same lasting benefit as the
purely intestinal ncuro-muscular tonics, and if
persevered m are apt to perpetuate the condi-
tion they were designed to cure The advantage
of sending cases of habitual constipation to one
of the many purgative spnngs is doubtful So
far as the cure of his constipation is concerned
the really important part of the treatment lies
in his acquiring there those habits of regular
hours, punctuality in attending to the call to
stool, systematic exercise, etc, which he can
follow out equally well at home The action
of the purgative waters is too often followed
only by a recurrence of the constipation on their
cessation
Again, when theio is sluggishness of the liver
present, hepatic stimulants, tg euonymm, or
podophyllm, are called for, but such drugs must
be adopted as meie temporary additions to the
systematic treatment of the constipation in the
manner stated above
Lastly, in some obstinate cases of constipation,
is prcMously ref cried to, an opiate (often com-
bined with belladonna) will open the bowels
when various cathaitics have failed, apparently
by allaying the reflex inhibition of peristalsis ,
and in a similar fashion an opiate may be advan-
tageously combined with a purgative if spasm
or pain be a prominent feature in the case.
ConstitlienS.— The vehicle 01 cxcipicnt
m a piescription, giving consistence, 01 helping
to remove disagreeable tastes or smells /S'ee
PllLSCHIBING
Constitution.— The paiticular way in
which an individual leacts to external circum-
stances, and resists 01 yields to moibid influences ,
predisposition to develop special forms of disease,
eg nervous, ihcumatic, gouty, and the like,
tempeiament Among the constitutions or tem-
pciaments which used to be much dwelt upon
wcie the nervous, the phlegmatic, the bilious,
the sanguine, the gouty, etc
Constitutional Diseases. — In a
somewhat loose fashion it is permissible to
speak of certain diseases, e g gout, syphilis, iheu-
matism, tubercle, rickets, rheumatoid arthritis,
acute and chronic alcoholism, diabetes melhtus,
homiophilia, obesity, and some nervous maladies,
as being constitutional, > e developed as the re-
sult of certain inherited or acquired moibid
modes of action of the tissues and organs Nee
under the above-named diseases
Constrictors.— Muscles which dimmish
the calibie of vessels or the capacity of hollow
organs by their contraction, e q the constrictors
of the naies, of the vagina, of the bladder, and
of the pharynx (fee PiiAinN\, AMECTIONS,
Nemove*)
Consultation. *SVe ETIQUETTE, MEDICAL
— The deliberative consideration of a medical or
surgical case in which the diagnosis, or prognosis,
or treatment is not clearly indicated, or is not
thought to be so by the patient or his fncnds,
with a view to greater accuracy and benefit ,
two or more practitioners may take part
220
CONSUMPTION
ConSU ITI pt ion.— A wasting away, espet i-
ally that due to tubercular disease of the lungs ,
galloping consumption is the name applied to
the more rapidly advancing foim of phthisis
See GASTRO-lNTESTIN'AL DISORDERS OP iNtANCY
{Chronic Dianluva, Consumptive Jioivefs) , LUNG,
TUBERCULOSIS or
Contagion. — This word (contagion), fiom
the Latin contingo, 1 touch, is often used almost
as a synonym of infection , but, stiictly speaking,
it means the communication of a disease from
one person to another, directly (immediate) or
tndnectly (mediate, 01 by a third person), by
means of a " participate or sensible material " or
" contatfium. " , the same disease is produced in
the second person as in the hist, and it also
has the same power of being passed on, by con-
tagion, to another jwrson Nee TIPIIUS FEVER
(Etiology)
Continued Fever.— A now little used
name for a fevei in which the tempeiatuie
varies little during the twenty-four hours, but
which steadily pi ogresses (without nitei missions)
towards its height, and thereafter slowly declines,
or may, when at its height, terminate fatally , it
was applied to relapsing, typhus, typhoid, and
other fevers , such terms <is itnipfe continual,
malignant continued, niiawuitu continued, and
ardent continued fever arc practically obsolete
See TROPICS, UXCLASSED FKMHW OP (Continued)
Contracted Kidney. See NEPHRITIS
(Renal Cm how)
Contraction. See Pin MOT/MY, TISSUES
(Muscle, Physical Ctiatftctetv, Conttaitwn) ,
LABOUR, KETENTIO\ OP PLACENTA (/low -f/lav>
Contraction of Uteius), LABOUR, PROLONGED
(Pelvic Defoi'nutte*, Contraction)
Contract!! re. — Pei manent contraction
(eg of a muscle) with rigidity, after convul-
sions, paralysis, or rheumatism , it is sometimes
distinguished as hysterical, myopathic, neuro-
pathic, 01 paralytic tfee BRAIN, AFFECTIONS OF
ULOOD- VESSELS (Paialyw, Rigidity), BRAIN,
TUMOURS OP (Symptoms, Tonic Xpawi) , BRAIN,
CYSTS OP (Porencep/uily) , FACIAL NER\K, PARA-
LYSIS OP (Symptom*, Conttacture) , HusIoiNT,
DISEASES OP (Neiiro-Atthropathies) , HYMFERIA
(Motor Disorders, Paralysis and Contract utes) ,
HYSI-ERIA, SURGICAL ASPECTS OP (Ilyvtencal
Contract™ «*), JOINTS, DISEASES OP (Impaired
Mobility, Conttacture) , KNEE-JOINT, DISEASES
OP (Def 01 nutlet following /Jumw, Contracture) ,
MALI NUBBIN a (Contracture*) , TBTANY (Synonyms
and History)
Contraindication.— The condition or
state of the patient which indicates that some
drug or some method of diagnosis or treatment
cannot safely or with benefit bo employed.
Contre- Coup.— -The effect of a blow
(eg a, contusion of brain substance or a fracture
of a bone), produced either exactly opposite
to or at a considerable distance from the site
of the stroke See BRAIN, SURGERY OF (Con-
dition)
Contrexevllle. See HALNKHOM
(Fiance, Calcaieous) , MINERAL WATKRH (Earthy
and Calcareous)
Control. See PinsioGMWY AND EXPRES-
SION (Expression of Jinn n faculty, Control)
Control Experiment.— An e\peu-
ment made simultaneously with another, in
which all tho conditions, save one, ate the same ,
a check 01 test expeinncnt
Contusions.
CAUSES 220
MORBID ANATOMY 220
CLINICAL FFAILRES 221
TREATMENT 222
MEDICO-LEGAL ASPECTS 222
DEFINITION — A contusion may bo defined as a
traumatic laceration of the subcutaneous soft
tissues of a part, without solution m the con-
tinuity of the skin When the integument gives
way a lontiised wound results
CAUSES — The JOICP producing a contusion is
always applied by a blunt object, is momentary
in its action, and immediate in its effects It
may be m the form of a direct blow acting per-
poudiculaily to the suiface, .is in the case of a
stroke with a stick, or a blow with tho closed
fist, or the force may impinge obliquely, as
when a spent shot glances oft the body, or a
carriage wheel grazes a limb m passing The
damage resulting iiom a " percussing " force
acting at light angles to a part is more 01 less
localised to the seat of impact, but may extend
deeply , vhile the effects of an obliquely directed
stroke tend to be more diffuse and superficial
At tho same time theie may be much teanng of
the subcutaneous tissues fiom the lattci foim
of violence
On the other hand, a part may be contused
by "pressuie," as when a limb is squeexed be-
tween buffers, or crushed by a waggon \thcel
passing over it The resulting lesions aie more
widespiead and deeper than in the case of injuries
by percussion
MORBID ANATOM\ — Three degrees in seventy
of contusions are recognised
In ttiejint degree or contusion with ecckymosis
theie are small, interstitial, petcchial htcmoi
rhages resulting from the rupture of minute
blood-vessels m the skin, with slight codema of
the whole of tho injured part The effused
blood is as a rule spontaneously and rapidly
reabsorbed
Second degree or contusion with extravasation
CONTUSIONS
221
of blood — The extent and character of the
effusion in contusions of the second degree
depend upon the looseness or density of the
connective tissue of the mjuied p«nt, the size
and nature of the damaged vessel*, and the
degree oi foice employed to pnxlucc it
It may be that .ill the tissues aie infiltrated
with blood fioiu a number of toin veins and
small arteries, 01 that the blood from ,i ruj)-
turod arteiy oi large vein collects in a single
space, constituting a /upmatonui
In either case the bleeding is soon arrested by
the giadually increasing pressure in the effusion,
and by the coagulation of blood in the tom
vesHels The extra vacated blood tends slowly
to diffuse itself along the lines of least resistance
-undei fiihcui', between muscles, into vascular
sheaths or connective-tissue spaces — so that it
may eventually reach the surface at some dis-
tance fiom the seat of injury This fact is
sometimes of nnpoitance in the diagnosis oi
in j unes, especially in teitun fractures of the
base of the skull, \vhere the ecchymosis appeals
aftci some days under the conjunctiva, or behind
the mastoid process
The majority of contusions tend to spon-
taneous cute The fluid pait of the extra vasatod
blood is reabsorbed by the lymphatics Some
of the red lorpuscles regain the general en dila-
tion dnectly or b\ the lymph stieam The
solid dot disintegrates ILjematoidm crystals
are precipitated in the tissues, gnmg them a
bluish, gieen, oi yellow coloui , and crystals of
cholestdin may form horn destruction of the
fatt\ elements of the clot The lemaining
debris is carried off by the lymphatics, and may
cause temporal y cnlaigement and pigmentation
of the adjacent lymphatic glands
The destroyed tissue is replaced by a ucatrix
formed by a process analogous to that known as
healing by tin* first intention
It is not uncommon for pioliferation of the
connective tissue surrounding an effusion of
blood to take place to such an extent that an
elementary membranous capsule is lormed In
this way a /uctnoir/uK/ic ct/\t is developed, the
contents of whuh may m course of time become
absorbed, or, after drying up, undergo calcareous
degeneration
Certain contusions result in the outpouring of
a largo quantity of wtous fluid instead of blood,
most probably from tearing of large lymphatic
vessels Tins is commonest after obliquely
directed blows or crushes, acting chiefly on the
superficial structures, especially when a tense
fascia underlies the akin Such effusions are
slowly reabsorbed, sometimes remaining un-
changed for months
In a few rare cases, especially where the con-
tused tissue contains much fat, or where a
fracture coexists, localised collections of an oily
fluid form, and are slowly reabsorbed
Thud degree or contusions with complete dis-
integration of tissue — When the vulnerant force
is extreme, and the resistance of the contused
tissues slight, their structure may be completely
destroyed M uscular tissue, blood-\ essels, nerves,
and connective tissues are reduced to a pulp,
the circulation through the part is suspended,
and the vitality so depressed that necrosis takes
place The overlying skm becomes cold, livid,
and dark-coloured, and blisters containing herons
or bloody fluid may form on the surface If
septic infection be prevented dry gangrene takes
place , but li bacteria gain access suppuration
and moist gangrene ensue
CLINIC u KB \TUHES — The chief local pheno-
mena of ( ontusions are dis( oloration and swelling
When the rendition is of the first degree minute
punctate hemorrhages aie seen scattered through
the superficial layers of the skin o\er the affected
area These are separate from one another, of
a light colour, and with slight adcmatous
swelling aiound them
Contusions of the mow/ (fa/tee are those most
commonly nu»t with The effused blood occurs
in patches varying in sue and depth with the
degree ol force which produced them, and m
shape with the instrument employed Where
the skin is naturally thin or pigmented, as over
the inner aspects of the aim, in the eyelids,
scrotum, and perineum, the discoloration tends
to bo darker than elsewhere \V hen the extra-
\asated Iriootl is only separated from the oxygen
of the air by a thin layer ol epideimis or by
mucous membrane, it retains its bright arterial
colour This is often well illustrated in cases of
bl,ick-eye, where the blood effused under the
conjunctiva is bright red, while that in the
eyelids is almost black
" The disc oloration rnav tike some days to
appear on the surface li the primary effusion
has been deep-seated among the muscles and
under sti ong fasc lal bands and in these circum-
stances it may appeal sonic distance from the
seat of injury The presence of blood extra-
vasatcd deeply in the tissues can, however , often
be detected by the firm, resistant, doughy swell-
ing whu h exists On deep palpation a peculiar
sensation, elosely simulating the crcpitus of
fractures, is sometimes transmitted to the
fingers, and is liable to lead to errors m
diagnosis
The changes w Inch take place in the effused
blood lead to characteristic alterations in the
colour of the contused part In from 18 to 24
hours the margins of the blue area become of a
violet hue, and as time goes on the discoloured
area increases in sue, and becomes successively
green, yellow, and lemon-coloured at its margins,
the central part being the last to change its hue
The rate at which this play of colours proceeds
vanes so much, and depends on so many circum-
stances, that no time limit can be laid down
A large bruise over the ami of a healthy person
may disappear completely in two or three weeks,
222
CONTUSIONS
while one of corresponding size and severity
over the pelvis of a weakly patient will persist
for as many months
In all contusions of the second degree theie
is marked swelling of the whole area involved,
especially \vhen the subcutaneous arcolar tissue
is abundant and open, au in the eyelids, scrotum,
penis, and labia
In contusions of superficial parts there is
always at first great jmin and tenderness on
pressure, but it soon passes of!' When dense
fascice, ligaments, or periosteum are involved
these symptoms are more severe and lasting
Traumatic neutalgia along the course of a
bruised nerve -tiunk is not uncommon, and
marked hypti cpstheata o\er a bruised area fre-
quently persists for a long tune Although the
degree of thock is not always propoitionato to
the seventy of the injury, sudden vywcpe fre-
quently results fiom severe bruises of the testicle,
abdomen, or head, and occasionally marked
nervous detention follows these injuries The
function of a bruised part is always seriously
interfered with while the effusion and swelling
last The only evidence of genoial constitutional
disturbance is a temporary elevation of teinpeia-
ture to 102° F , or even higher — a form of waste-
product fever Among the rarer clinical features
may bo mentioned general antrrnw, when the
local effusion of blood is veiy great , traumatic
icterus, when the blood pigment is deposited
throughout the skin of the body, and fat
embolus, which is usually associated with a
complicating fracture
The clinical features of contusions of the thnd
degree are of secondary impoitance to those of
the graver mjuiics \\ith which they are usually
associated — fractures, dislocations, laceiation oi
large vessels, nerves, or muscles— conditions
which m diagnosis and treatment ovci shadow
the accompanying contusion
TREATMENT — The mam indications are (1) to
prevent the fuithor effusion of blood , (2) to
alleviate the pam , (3) to maintain the vitality
of the damaged tissues, (4) to piomoto the
absorption of the blood and lymph already
extravasatcd , (5) to avoid, or (6) to combat,
bacterial infection
If seen immediately after the accident the
part should bo placed at absolute icat m a
slightly elevated position Firm elastic pressure
through a thick pad of cotton-wool is of great
value in arresting the effusion , and cold (m the
form of ice), lead and opium lotion, or a weak
carbolic compress, are useful adjuncts
When cxtiavasation has already taken place
massage is the speediest and best method of
dispensing the effused products The part is
deeply kneaded and nibbed in a centripetal
direction once or twice daily, and the patient
is encouraged to move the part freely after each
sitting, in order that the muscular movements
may augment the action of the rubbing Any
abiasion of the skin of course contramdicates
the employment of massage
When the effusion is so large and so tense as
to threaten the vitality of the tissues au incision
may be indicated, but is only to bo practised
when the certainty of maintaining asepsis is
assured
Septic complications will be met on general
principles by incision and drainage, or, if neces-
sary* % amputation.
MEDICO -LEGAL ASPECTS OF CONTUSIONS —
Contusions ha\e often very important medico-
legal beat ings When called to see a suspicious
case the practitioner should note (1) the date
when the bruise is alleged to have been inflicted ,
(2) the date of the examination , (3) the degree
of the contusion and the precise colours exhibited
at the time of examination, as an indication of
the approximate age of the ewhymosis, (4) the
shape of the discoloured area, in association with
the character of the instrument with which it is
alleged to have been produced , (5) the presence
or absence of CMdence of such complications as
fracture, dislocation, external wounds, or injuries
to internal oigans
It is well to boar in mind that those suffering
from scurvy, hiemophiha (bleeders), and fat,
antcmic persons in a low state of health may
l^e extensive ecchymoscs produced on their
bodies by very tuvial injuries, and fuither that
ccdiymosis may occur, apart from external
injury, Irom violent muscular efforts, as m
attempting to recover one's balance, or during
severe vomiting or other form of straining It
is also worthy of note that many old people
with weak circulation have darkly discoloured
patches on the legs and feet which closely re-
semble contusions, and might bo mistaken for
them on the cadaver The necessity for dis-
tinguishing between bruising and post-nun tcm
hvidity need only be mentioned
On the other hand, the absence of ecchymosis
dues not piovo that no external violence has
been inflicted, as severe blows, especially over
the abdomen and thoia\, are often not followed
by cxteinal signs of bruising, even although
inteinal organs are seriously damaged
Violence inflicted on a living body may not be
manifested by ccchymouis till after death, while
blows dealt on a recently dead body (within two
hours of death) may produce signs exactly like
those occurring on the living If, however, the
body bo cold and cadavenc rigidity has set in,
the appearances of contusions on the living
cannot be produced by external violence
If a bruise on a dead body be found uniformly
blue 01 livid, the presumption is that the blow
was struck immediately befoie death, while a
play of colours round the margin suggests that
some time has elapsed between the infliction of
the injury and death That the effused blood
has remained fluid is not proof that the contusion
was sustained after death.
CONTUSIONS
223
Evidence of the previous existence of a bruise
may be found for some time in the pigmentation
of the neighbouring lymphatic glands
Con US ArterlOSUS.— The conical pro-
longation of the upper and loft angle of the
right ventricle of the heart , the infuiidibulum ,
its stenosis constitutes one of the varieties of
congenital hcait disease. See HEART, CONGENITAL
MALFORMATIONS OF
Con us Medullaris. — The conical
termination of the spinal cord \vlnch lies im-
mediately above the slender fihtm terminate , it
lias been injured during lumbar punctine
Convalescence. — The period of
gradual restoration to health after an illnoin
See INVALID FEEDING (Diet during Convale vence) ,
PuMti'ERiUM, Pin MOLOGY (Management), T\ PIIUID
FE\KR, etc
Con vail aria Majalis.— The leaves,
stem, and flowoiH of the lily of the valley con-
stitute the non -official medicine (Convatlntia
Afaja/is) } convallamai in (02JH44012) is the active
principle, and the plant contains al&o conml-
larin (U,4H,)2On), both of them glucosidcs, the
Ttnctura Coiivallarw (made from the flowers)
is given m doses of 5 to 20 m in the same
class of case as digitalis See PHARMACOLOGY ,
DIGITALIS
Convergence. See ACCOMMODATION
(Accommodation and Convergence), BRAIN,
PIIYHIULUUT OF (Third Nerve, Median Nucleus) ,
EYE, CLIVICAL EXAMINATION OF (Visual Acuity,
Power of Convergence) , OCULAR MUSCLES,
AFFECTIONS OF (J'aialyn*, Sf/intit) , STRABISMUS
Convolutions of the Brain. See
BRAIN, PHYSIOLOGY, BKOOA'* CONVOLUTION,
G> RUS, PHYSIOLOGY, NERVOUS SY STEM (Cerebrum)
Convulsions.— Violent iriegular motion
of the \\holo body or parts of it due to in-
voluntary contractions and relaxations of the
voluutaiy mubclcs, different varieties aie
apoplectic, cataleptic, choreic, dome, eclamptio,
epileptic, epileptiform, hysterical, infantile, in-
ternal, mimetic, oscillatory, puerperal, salaam,
tetanic, tonic, and ui.emic See ANKURYSM
(Common Catotid, Treatment ly Ligature),
ANTISPASsMODICS , BRAIN, AtPECTIOhb OF BLOOD-
VESSELS (Anfvnna, (Edema), BRAIN, AFFECTIONS
OF HLOOD-VKHSKLH (T/nomboiis, Vascular Lesion*
and their Results) , BRAIN, INFLAMMAI IONS
(Clinical Fentui et>) , BRAIN, TUMOURS OF , BRAIN,
CEREBELLUM, AFFECTIONS OF ( Tumour) , CONVUL-
mONS,lNFAN1ITR, GAH'l RO-lN'lESTINAL DISORDERS
OF INFANCY (Chtonv Dttnthuea, Complication s) ,
GENERAL PARALYSIS (Diagnow) , HYSTERIA,
LABOUR, OPERATIONS (Forceps) , MEASLES (Con-
vulsions), MENINGITIS, EPIDEMIC CEREBRO-SPINAL
(Symptoms) , MENTAL DEFICIENCY , NOSE, POST-
NASAL ADENOIDS , PARALYSIS (Cerelnal Diplegia,
Infantile Jlenujdeyia) , PREGNANCY, AFFECTIONH
AND COMPILATION. s (Nervous System^ Convul-
sions), SYPUILIH (Childten, Nervouv System),
TOXICOLOGY (Lead) , TRADES, DANGEROUS (Lead-
Poiwtnng) , UNCONSCIOUSNESS , UILUILA
Convulsions, Infantile.
FREQUENCY
ETIOLOGY
SYMPTOMS
PROGNOSIS
TREATMENT
223
223
224
224
225
See also OONV ULSIONS
The term convulsions is applied
to more or less general purposeless muscular
con ti actions, occumng simultaneously and buc-
ccsbively for a variable time, attended in most
instances by a lob.s of consciousness more or less
profound The more strictly local muscular con-
tractions aie more appropriately and conveniently
denoted as bpasm
FREQUENCY -The frequency of convulsions m
infancy has been gicatly e\aggeiated, especially
ainonght the lay public
The convulsive movementb of the limbs seen
m moiibund child i en, mainly due to the venous
state of the blood, must not be considered in
the same categoiy
ETIOLOGI — The causes of convulsions can be
divided into predisposing and exciting, of \\hich
the former are the more nujiortant
Ftedfipohing Causes — 1 All wntera seem
inclined to place as foremost amongst the pre-
disposing causes uhat has been teimed the
instability ot Mutability of the infantile nervous
system This instability disappears \\ith ad-
\ancing age and the further development of the
higher centres
2 An inherited neurotic tendency or consti-
tution is a veiy impoitant factor Published
statistics give a neurotic history in 32 per cent
of the parents , and if convulsions in bi others
and sisters of the patients are consideied, then
the family ncuiotic history uses as high as 67
per cent The importance oi this factor in the
causation of convulsions has not as yet been
sufficiently recognised and acknowledged
3 Rickets is a furthei piedisposmg cause
Whilst, ho\ve\cr, a very laige pciceiitage of
convulsive infants are rachitic, yet convulsions
do not occur in ccitamly more than 5 per cent
of all eases of tickets When convulsions occur
m this last they are frequently associated \\ith
laryngismus stridulus and tetany The ex-
planation of the occurrence of all three dis-
ordcis is, perhaps, due to the brain suffering in
the general malnutrition with the rest of the
body m rickets
Exciting Causes — Almost any central or
penpheral lesion in infancy may act as an
exciting cause, especially in subjects predis-
224
CONVULSIONS, INFANTILE
posed. The more common conditions may be
thus classified • —
1. Local disease or injury of the brain or its
membranes, eg mtracramal tuniom, htcnioi-
rhage, meningitis, etc The symptoms of
cerebral tumour in young children often pre-
sent themselves \\ith a stattling abruptness,
and convulsions at the onset may be general in
character If the convulsions date from buth
they are generally due to inemngcal hemor-
rhage, and aie often associated with paralysis
and subsequent amentia In not a few cases of
meningitis, convulsions may be the first promi-
nent symptom, and such convulsions may be
unilateral in chaiacter
2 Altered vascular states, as antenna, follow-
ing haemorrhage or exhausting disease from any
cause, venous engorgement, 01, nioio rarely,
uncima
3 The onset oi the acute infectious diseases,
eg pneumonia, etc The frequency of this
relationship has been largely overestimated, con-
vulsions being much moic frequent in tfa course
of such affections, and then usually dependent
on the venous state of the blood (asphyxia)
4 The developmental conditions resulting in
idiocy
5 Peripheral neive irritation Teething dis-
orders and gastio-intestmal derangements aie
important lactois in predisposed subjects
Severe surgual mjunes, such as extensive hums,
may certainly cause convulsions in infants in
whom no predisposition is to be found
6 Asphyxia The important pait played by
asphyxia is peihaps not duly appreciated by the
profession generally This association clinically
between asphyxu and convulsions is in strict
accord with physiological experiments. Illus-
trative examples have already been given The
convulsive movements seen in vaiious moribund
states are piobably also of similar origin
PAHIOLCMTY — The leal pathology of convul-
sions is as yet undetermined The post-mortem
changes tound m the brain and cord are in all
probability results and not causes of the dis-
order Probably the ultimate pithological
processes concerned will l>e found in moleculai
changes m the neive cells, rather than in
changes capable of demonstration with any
means yet at out disposal When the patho-
logy of idiopathic epilepsy is revealed to us,
the discovery of that of infantile convulsions
will bo close at hand
SYMPTOMS — The phenomena of a typical
attack of convulsions are identical in character,
time, and sequence with those occurring m an
epileptic fit, and require no detailed description
In both disorders the attacks generally com-
mence with a dazed or "far-away" expression
of the face, immediately followed by momentary
pallor and dilatation of the pupils These are
closely followed by loss of consciousness, during
which the muscles are affected at first with
tonic spasms and apuoea, succeeded after a
variable interval by clonic contractions In
both convulsions and epilepsy there is frothing
at the mouth, blood-stained if the tongue bo
bitten, and in both there may bo involuntary
discharge of urine and fax.es The attacks
always conclude with a period of drowsiness
more or less profound Several of the phe-
nomena may be but slightly prominent or even
omitted, and convulsions, like epilepsy, may
\aiy m their intensity between the widest
extremes A conspicuous feature of infantile
convulsive attacks is the well-known turning in
oi [the thumbs upon the palms of the hands,
with flexion of the fingers around the thumbs
Convulsions may come on suddenly in the midst
of apparently perfect health In other cases
theie may be warnings in the shape of fretful-
ness, squinting, grinding of the teeth, and turn-
ings in of the thumbs upon the palms of the
hands
DIAGNOSIS — If the child bo seen in the attack
the diagnosis can present no possible difficulty
When it has to be made from the verbal accounts
of the patents or fi lends, then the utmost caution
and discrimination will have to be used The
too re.uly acceptation, without caieful inquiry,
of the laity's interpretation of what constitutes
convulsions, has helped to spicad and perpetuate
•ui exaggciated impression of the ficquency of
convulsions ptoper even amongst the members
of the medical profession
PioynoM* —The immediate prognosis is gener-
ally favourable When the attacks so rapidly
follow one .mother as to be merged into one
long series (status convulsivus), then death may
ensue fiom exhaustion This List condition--
"status convulsivus" — diffeis in no lespect
from the "status epilcptieus" of .idults, except
that in the younger subjects the temperature
runs much higher and generally reaches 105° oi
upwards Death, too, is not very mirequent in
convulsions associated with laryngismus stiidu-
lus, but here the last-named is possibly mote
often responsible for the fatal issue than the
concomitant convulsions Convulsions arising
during whooping-cough are often fatal, more
especially if the infant's health has been much
reduced by vomiting or other complication
When broncho-pneumonia is marked by urgent
dyspnoea, convulsions, due to asphyxia, are not
infrequent and are generally fatal, but the con-
ditions preceding them in this instance are of
evtreme gravity independently of them
In most cases the remote prognosis of an attack
of convulsions should be a guarded one There
is seldom anything m the phenomena of the
attacks that furnishes any criteria enabling one
to discriminate between convulsions likely to be
followed by later neurotic manifestations, and
those that are of merely temporary import.
Prognosis then must depend less on the pheno-
mena of the attacks than on their history and
CONVULSIONS, INFANTILE
225
the circumstances which attend them. Here,
howevoi, it may be said at once that the same
greater significance attaches to unilateral con-
vulsive attacks in all cases in infancy a» to those
occurring in later life Favourable factors aie
a history of previous good health m the uifdiit,
and the presence of some well-defined exciting
cause, such as the onset of one of the exanthe-
mata 01 croupoiib pneumonia The prognosis is
favourable, too, in cases \vhcre the convulsions
can be shown to have mainly depended upon
asphyxia, the cause of winch has been icmoved
or lecoveied ftom Where theie is a family
ntmiotit history the piognosis should be guarded
in the extreme Caution should be used, too,
m pronouncing as to the futnie of an infant
who has suffered from convulsions presumably
fiom biicb slight causes as dentition, bo\vel dis-
turbance, 01 ascamles, foi it may well be asked
whether .1 neivous system that has once bioke.ii
down nuclei such slight causes would not be
hkoly to do so again m the futmc at any times
of ceiebuil stiess 01 strain beyond the oiduiary
Convulsions occurnng in the (oursc, not at the
onsotot scailetfevoi, and whuh are independent
of any kidney involvement, «ue often uinl.itci.il
at the commencement, and ate fiequeiitly con-
tinued into latci life as epilepsy When the
convulsions occui in association with nckets,
nnpiovemcnt in the List complaint genoi ally leads
to tho hnal diMppeaiancT of any disturb.uicc of
the neivous system But even beie Kir William
Uovveis has shown that 10 per cent ot adult
epileptic s have then st.ut in infantile convulsions
due to rickets, awl in juvenile epileptics the
piopoition is piobably gieatei This should
lead to a moie guaidccl piognosis than is usually
given in cases of lathitic convulsions (Vises
wheio convulsions lecin from time to tune with-
out oigainc cause aic> to be legal (led in the most
senous light, a Luge piopoitiouof them merging
into epilepsy in the ncai future, -while otheis
aic piobably the subjects of othei neuioses in
later life
TREATMENT — Duun</ the Attach — In the
majonty of instances it is only necessaiy to
loosen the clothing about the neck, chest, and
abdomen, and to lay the infant in the supine
position with the head slightly laised Tho
infant can then be loft to iccovci fiom the
drowsiness natiually following, or ioiming pait
of, the attack The ordinary domestic- lemedy,
placing the child in hot bath, docs no harm
probably if the child's health be not too en-
feebled In this last condition, instead of a
plain hot 'water Kith, a mustaid one might >*>
tried vuth advantage for the sake of its AV ell-
known stimulating propel ties Thei P is nothing
to bo said in favour of the other loutine remedy,
the application of cold to the head, except in the
cases where it is used for the express puipose of
lowering the temperature If the unconscious-
ness be unduly profound, and especially if it be
attended with othei fits, or threatcnmgs of them,
then lecourse must be had to more active
mcasuies first amongst these is the inhalation
of chloroform, which is \vaimly advocated by
Henoch, John Thomson, and other authorities
Profound unconsciousness is no bar to the use of
the drug, and usually recoveiy fiom the amcs-
thetic is accompanied by t]be return of conscious-
ness Eustace Smith praises the hypodermic
injection of moiphia in these cases in doses of
A °f «>• gram to an infant of six months old, and
says it can be safely icpeated, if necessary, in
the < ourse of half an hour The inhalation of
tutntt af <imyl m one -minim doses has been
lecommended by some authorities The admin-
istration oi thloidl by cncmata, in doses of about
f hiee plains to an infant of six months old, is a
valuable lemedy for two reasons If the drug
be u'tamed its sedative action on the nervous
system is uhiially quickly manifested In other
cases its presence in the lectum leads to the
evacuation of ,m especially foul-smelling motion,
rind this is generally followed by a speedy return
of consciousness It theie be any valid reason
for suspecting indigestible food to be responsible
for the distui bance, then au emetic may be
given, followed by a calomel puige In "very
exceptional instances theie may even be some
justification foi the employment of the gum
lancet
Mubw/aiitt Treatment — For a few days after
a fit small doses of one of the bromides, two or
three gi.uns, should be given thiice daily If
the child be syphilitic 01 iickety then the
appropriate tieatrnent foi these complaints
should be* vigoiously employed The greatest
caio should be bestowed on the diet, and on the
thoiough ventilation of the day and night
cipai tiuents AiiaiiKcmciitb should be m.ule for
the child's bead being itused dunng sleep and
the leet being kept w aim li the convulsions
iwii with .my tuumcncy, say, every fortnight,
01 even eveiy month, then a coiuse of hioimdes
should be piesciibtxl Kveiy attack possibly
lessens the lesistanc e m tho ueive tr.u ts, so that
succeeding fits occurvuth much slighter exciting
causes th.u» the initial onus l$y allowing the
fits to continue much inoic haim may thus be
done than any th.it may jwsHibly aiisc fiom the
efiects of tho In onndcs on the dev eloping tissues
It is chfhcult to fix d definite time, but pcihaps
a freedom of three1 months tiom fits should
ensue befoi e stopping the1 bi onudes Belladonna,
tho silts ot xmc, digitalis, eigot, musk, and other
lemedies that have been vaunted fioin time to
time m the tieatment of convulsions, aie much
less cthiacious than the bromides If the
bromides fail in cheeking tho convulsions, then
hoi ax, in two-giani doses, might be gi\en a
trial
Convulsive TIC. — Involuntary mus-
cular movements, especially of tho face, accom-
15
CONVULSIVE TIC
panied by "explosive utterances," such as the
repetition of an offensive or meaningless woid ,
habit chorea or habit spasm See CHOREA
(Diagnosis)
Cooking. See INAALID FEEDING (General
Preparation of Food), FOOD (Cooling, K/ect*>
of), PHYSIOLOGY, FOOD AND DIGESTION (Conk-
ing)
COOper, Astley. See HERNIA (Fetnoral,
Variety), SHOULDER, DISEASES AND INJURIES
(Dislocation^ Si.' Astley Coopet'* Method of Re-
duction)
. — Thoh-anioniousactum
of two or more musclts or sets of muscles,
under the direction of the \\ ill, and foi the purpose
of cariyim* tlnough a complicated act See
ALCOHOLIC M ( Chi omt).
Copaiba. See BRE\TH (Clinical Dia-
gnosis) , DRUG ERUPIIONS (Copaibn) , NEPHRITIS
(Acute, Ettolorjy) , PHAHMACOLOGY , PRESCRIBING,
PURPURA (SymptomatH , Tone), URINE, PATHO-
LOGICAL CHANGES IN (Odfnn) —An oloo-iOMii
obtained from rations species of Copaifeia (c g
C Lan</vdorjii, C officiwiliv, et( ) , it is insoluble
in water, but is dissohcd in absolute alcohol,
ether, benzol, etc , it contains an oil (the
official Oleum Coj)aiba>, gnen in do-»cs of B to
20 in suspended in mucilage of aca< ia 01 \\ Into
of egg), and a icsin (containing topamc acid,
C10H30(\,) , it lias an aromatic odour and a dis-
agreeable tiste , and it is given in doses of \ to
2 fl di (in mucilage of acaua) Tlie chief
action oi copaiba is <i stimulating one upon the
mucous membranes of the genito-minai} ti.ut,
of the intestines, and of the lungs It has been
found to be specially useful in gononhcoa aftei
the acute stage has passed , it is also employed
(for its disinfectant and diuretic action) in
cystitis, pyehtis, and in hepatic and caidiac
dropsy Its effect upon the breath is an incon-
venience, and its nasty taste lequnes to be
disguised See PRESCRIUIMJ
Copper. See PHARMACOLOGY , PRESCRIB-
ING, STOMACH AND DUODENUM, DISEASES OF
(General Etiology, Toxic Substances in Food) ,
TOXICOLOGY (Aisentte of Cop]ter, Copper) ,
TRADES, DANGEROUS (('operand Rtan) , URINE,
PATHOLOGICAL CIIAN<»KS IN (G intone, Tionmiei'i
Teit) — The only othcial form of coppei is Cujn i
Sulphas, " bluestone " It occuis in the foim ot
irregular deep -blue cijstils, solu))le in \vatei
and with a strong astimgent and metallic t<iste
DOM — J-2 gr (astringent) , 5-10 gi (emetic)
Rluestone is applied to uleeis, to i educe
exuberant gianulations, to syphilitic soics, to
ulceisoi the mouth, to small cancerous giowths,
etc Lotions of st lengths Mir) ing fiom 1 to
10 gr to the ounce are employed for antiseptic
and astiingent pui poses in diseases of the eye,
vagina, urethra, etc Internally in small doses
it is given in the form of a pill m diairhooa and
bleeding from the stomach. In larger doses it
is a prompt emetic, and has been used thus in
laryngitis and bronchitis in children, and in cases
of poisoning It is specially indicated in poison-
ing from phosphorus, with which it forms a
stable, insoluble compound If it fails to pro-
duce emesis the stomach must be at once emptied
by other means, on account ot the powerful
irritant effec t of the drug Copper sulphate has.
been given empirically in A.UIOUS chionic nervous
diseases, but piobably no bciieht is derived from
it in such cases
Copra- Or Copro-. — In compound
woids topni- 01 co]>ro- (fiom (»i KOJT/JOS, fdoccs)
signifies i elating to the t.eces 01 to defecation
thus copiawiAHi is imoluntaiy defcecation ,
cojjtfFrma is the depiaved state of the body
due to prolonged constitution ,uid absoiption
of constituents of the t.eces, cojnayogue is a
cathaitic, <»jnolnlm is the use of duty uords „
cojnnftth it> an intestinal unuietion (focal) ,
coptophagy is the eating of itccal matixT, «md
copiostftw is the blocking ot the l>o\\el \vith a
haidened mass of fteces
Cor. — The heait, as used in such expiessions
as Cm adipowm, a he.irt sho\\ ing e\c ess of the
subperiL.iidicil fat , Cor tmnnwm, a hypuitiophic
state of the heart in \\lnch it comes to icsemble
a bullock's he«iit, CM hilotulaie (see HEART,
(yOVOEXITAIi MALtOHMAlIONh OP), a IlCcil t 111
which both septa aie defective, and so the heart
is double-chain be led 01 reptilian, Cm villovum
or Cot hn \ntum, a heait covered e\teinally with
threads of iibim, gtxmg it a shaggy appeal unco
CoraCO-. — In compound ^oids coraco-
(from (lr Kopag, a crtn) means i elating to the
coracoid piocess of the scapula, t f/ coi.uo-
clavicular, (or.uo-humeial, etc
CoraCOld Process. See SHOULDEU,
DISEASED AXD IviuniTs(A'i«rfic»6o/'f/M' Comcoid
Aorrst)
Coral CalCUlI. — Deudntic calculi, form-
ing in the pelvis ot the kidney and constituting
exact moulds of it
Cord. See SCROTUM AND TESTICLE, DISEASFS
or (Spnntfitit Cmd, Anatomy, Toi<non, I/wnui-
toma, and Hydiocele), SPINAL CORD, MEDICAL,
LABOUR, ACCIDENTAL COMPLICATIONS (Abnor-
malitie? of the Umbilical Cord)
Cordentery. — A teiatological state met
with in the chick , it is allied to omphalocephaly ,
and in it the notochord is elongated in the direc-
tion of the alimentary canal and in pait clothed
by it
Core-. — In compound \\ords core- signifies,
the pupil ot the eye (fiom (ii Kopr/, pupil), as
in corectasts, dilatation of the pupil , corectopta
displacement of the pupil (see IRIS AND CILIARY
CORE-
227
BODIES (Congenital Abnormalities of In*),
coreometer, an instrument for measuring the
diameter of the pupil , corepfasty, the formation
of an artificial pupil , corestenoma, a (congenital)
nan owing of the pupil , corocfettit, obliteration
of the pupil , corodia^ttms, dilatation of the
pupil, and cot onun pftons, the making of an
artificial pupil
Corlandri FructUS.— The hint of an
unihellifcious plant (Coiwndnim mtivuni) , it
contains an othci.il volatile oil (Oleum Cou-
anrlri), which contaniH coriandrol (C10H17()H)
and pincne, and is given in doses of J to 3 m ,
conandci fimt and its oil ha\e the caiminativo
and btomachic actions of the volatile oils, and
are used in the making of the Confettion and
the tiyritj) of Henna, in tiympui Jthei, m Tint-
tuna Rhei Composite, etc
Corfu m. fiee SKIN, A \ATO\n AND PHY-
SIOLOGY (Corium),
Corn. See CIAVUS, T\BES DORSALIS
(Peiforatma (fltci of the Ftxrt) — Coins aie horny
induratiOTiH or thickenings of the cuticle, situ-
ated usually ovei one or other of the joints of
the toes, and caused hy piessme irregulaily
distnhuted (ea tight 01 ill-iittmg boots), a
coin often develop^ a central core (or "eye")
which p.isses more deeply into the undei lying
stiuctmes and regimes to be taken out before
c 111 e can be effected, tieatrneiit consists in ic-
moving the exciting cause, e a by the \veaimg
c»f \\ell-htting boots, 01 by so distiibutmg the
piessuie (ft/ by a plastoi) as to prevent its
(oucentiation at any one point, the 1 010 c«in be
taken out by soaking in hot watei and then
sciapmg, ot couise, if a coin betoiue inflamed
and an al>s( ess fonn under it, it will he neces-
sary to poultice and open it
Cornea.
INFUMM \rioN OK
U ITERATIVE iNfcLAMMA'UON
OTHER AFFECTIONS —
Congenital Opacihe*
ATM* fienilit
Blood-Sim nmg
Keratitis Punctatu
Conical Cornea
llydrojdithnlmos
Tumour*
INJURIES —
Foreign Jtodu s
Fhn ?is
240
240
241
J41
241
241
241
2U
242
TYPES OF ULPERATIOX
Simple, Infective, Catanluil, tier pi yi
new*, Marginal Ditch, Rodent
JCet ato-Myi <HI « A vpergilh na
THE PiiiAoiKNUiiAR ULCER
BULLOUS ArFEr novs OF
Jfetpes, llapw Zoster, flendntir
Ulcer, Nupetlicial Punctate Keia-
titis, Jtecunent awl Fi/a
Keratitts
KERATO-MALACIA
ULCERATION FROM EXPOSURE
NEURO-I'ARALYTIC KERAINIS
INTERSTITIAL KERATITIH
KEKATITIS PROFUNDA
STHIAIED AND SCLEROSING KERATITIS
CALCAREOUS DEGENERAHON
227
22K
232
232
233
235
236
237
237
237
239
240
240
Xee alto BRAIN, (CEREBELLUM (Tumow, An<e\
then a of Cotnea), K\E, CLINICAL EXAMINATION
oi (Corntti) , GL \UCOM A (Synqttoms) , HERPES
j (Ocvlar Complications), HysTERiA (0<ular
I Anwthesia) , LEPROSY (Uic&ation of Cotnea) ,
| MKMNOIIIS, TUIJERCULOUS (Eye Symptoms) ,
KEHiAciiox(^^/(/»///^«tm), SrLFROTic', DISEASES
OF (tii/etotitiv) , SMALLPOX (Cornea! Ulcet) ,
SYPHILIS
Tin* eornea may bu consideied bioadly as
consisting of three laycis the anterior epi-
thelium, the jnoper coineal tiwue, limited by
t\vo stiuctureless elastic laiuin.e, Bosnian's
membiane in fiont, «ind Debcei net's membiano
behind, and the enttothehvm These paits ha\e
a common origin with the conjunctiva, v\ith the
scleiotic, and with the uvcal stiuctuies of the
eye Respectively, and the\ fire subject to the
same changes and shou the same tendencies
as the ]uits with which they ha\e origin The
cornea is not vasculai , it gets nourishment ty
a system ot lymph channels, and is abundantly
supplied with ner\cs
K\iMiffuroff of IHF CORNI < — The coinea
sh<mld )>e generally inspected as to shape, si/e,
deal ness, and the piesenee or absence of opaci-
ties Its sui face should then be examined by
placing the patient opposite a \\mdow, and
obserung the image i effected from the various
parts of the eornea as the eye follows the fingei
A breach ot smfacc ian be detected by a dis-
turbance of the image, it may then be \enficd
by staining with fluoiesune Fluorescinc 2 pel
cent, huaibonatc of soda 3 per cent in distilled
water The condition of the cornea geneialh
can be bcht m<ule out by examination by focal
light , finallv , the ophthalmoscope ma} IK* used
with a lens of high pown + 20 1) behind the
iniiioi
Kxammation by focal light is tamed out as
follows — A darkened loom, a source of light,
and a lens of about thice inches focal length
are nccessan The light is placed at about
eighteen inches on one side of the patient's
head, and is foe used b} the lens on the different
paits ot the coinea, the more obliquely the
light falls on the o}e the more clearly will
opacities be seen To obtain full advantage of
this method the cornea should be magnified by
a lens ot high power held in the othei hand
IMLAMMAIIOV ot THE CORNS \ — Keratitis —
228
CORNEA
Inflammation of tho cornea may bo limited to
the epithelial layer, to tho substance of the
cornea, or to tho endothehum on its postcnoi
surface, it may be a local infective process
loading to ulceration 01 abscess, or it may be
part of a disease affecting mainly the deeper
regions of tho eye , it is often the manifesta-
tion of a constitutional affection as in inheiitcd
syphilis Inflammation of the comca always
gives rise to a loss of transparency , if only the
anterior epithelium be involved, the surface
loses its polish, and tho appeal ante of stippling
produced by its cells when highly magnified is
exaggerated , sometimes the change in the cells
is so marked that the magnified suiface has the
appearance of a piece of oiange skin or shagreen
An exudation into the conical tissue pioper is
shown by a yellow or grey opacity , suppuration
is preceded by haziness, and the aiea of sup-
puration is surrounded by a similai aie.i of
haziness The effect of inflammation is to pro-
duce a blurring of the paits seen thiough the
cornea , thus the pupil is no longer quite black,
and the details of the structure of the nis art
obbcured
Inflammation begins \\ith an inhltiation , this
consists in the appearance of numbeis oi leuco-
cytes in the tissue of the coinea , the affected
area is rendered opaque and the suifaco over
it loses its polish This exudation sometimes
becomes completely .ibsoihud, and the coinea is
left quite tiansparent, at othei times whoie
tho disturbance of the coineal tissue has been
greater, or wheie the exudation has been
present for a long time, complete lostoratiou
of transj>areiicy does not take place, the exuda-
tion is coiiveited into ti hi OILS tissue, which
differs from the proper tissue of the coinea in
not being transpaient There is a tendency,
however, for old exudations to go on slowly
dealing for years, as is seen in the icmaikahle
way in \vhich the changes in the coineal sub-
stance left by interstitial keratitis disappeai
This clearance depends piohably on nutiition,
as wo commonly sec- the penphciy of tho coinea
clearing moic readily and more completely than
the central paits \\hich ate farthest removed
from the sources of nouiishment This also
probably explains the leason underlying the
use of irritating remedies and massage of the
coinea in the promotion of dealing of opacities
of old standing
UIX'ERATIVE INPLAMMAI-ION — If the inflam-
mation be of an uleeiative nature the exuda-
tion goes on increasing in amount, the cortical
tissue is broken down, and eithei an ulcer or
.in abscess is pioduced Suppuiaticm generally
starts m the supcificial layers of tho cornea,
the epithelium becomes cast off fiom the in-
filtrated area and .in ulcer is formed, m the
earlier stages, while the margins or base of the
cornea are infiltrated with leucocytes, the ulcer
is progressive As recovery takes place the aiea
of initiation disappears, the ulcer becomes
clear and transparent, but the surface is still
rough Giadually the epithelium from the
edges grows ovei the surface oi the ulcci, and
blood- \essels inn in fiorn the margin of the
cornea beneath the epithelium, the ulcer is
healed, but its level may be lowei than that of
tho icst of the cornea By the development
of fibrous tissue beneath the newly formed
epithelium the level IB gradually laised, but
the tianspaiency of the cornea is nnpaiied by
this growth of fibious tissue, and the seat of a
foimci ulcer may be tiacod for years by the
opaque scai lying in the clear coinea
Most of the pus-producing organisms have
been found in uleeiative affections of the cornea
In the eaily days of bacteiiological woik on the
coinoa the staphylococcus and stieptococcus
weie thought to be the most fiequeut pro-
vocative agents, whothei the ulceiation was
pinnaiy 01 the lesult of uijuiy, but owing to
the work of Uhthofl, Axenteld, Moiax, "and
othei s, wo now know that they aie piesent
much less frequently than other organisms
The ulcei.it ions which occur (lining the com so
of attacks of conjunctivitis .lie not due to
secondary infection by staphjlo- 01 stiopto-
cocci, but aie caused by inoculation of the
tot 110.1 with the organisms of the conjunctivitis,
and wo may thorefoie hud tho gonococ'cus, the
Weeks' bacillus, the* diplobac illus, and otheis
The chaiacteis of the ulcoiative piocess vary
with the nature of the infecting oigamsm, and
although we are not >et in the position of being
able to make a ne\v classification of coinoal
ulcers on this basis, yet ceitani tacts aie \\ell
ascertained Ace oi ding to the icseauhes of
Uhthoff and Axouteld, in .is many as 9H per
cent of the cases of acute serpiginous ulcei
pncumococ c i we're piesent In ceitain sei-
pigmous ulcci s limning a much less acute
course, attended by little or no pain, a diplo-
bacillus lesemblmg somewh.it the chplobacillus
of chronic conjunctivitis, but having some dis-
tinguishing chaiacteis, has been found (Petit)
In bilateral infantile ulceration of the cornea
(kciato-malacia) the pneumococcus has been
found and also the stieptococcus The Asper-
gillus fumigatus has been found growing on
the coinea in some lare instances
The htktolofjy of «ytneal vuppuvation h.is been
very thoroughly investigated by Lcbci, who by
his obsei vations on the cornea has added largely
to oui knowledge of the inflammtitoiy process
in geneial
Accoidmg to his obscivations the entianco
of any pyogenic organism into the tissue oi the
cornea sets up hyperromia of the paits round
tho cornea This is brought about by the
irritative action of the toxmes developed m
the coineal tissue by the growth of the organism
Very soon an invasion of white cells spreads m
from the periphery of the cornea, each cell
CORNKA
229
making its way through the lymph channels
till it roaches the infected aiea Heio two
things may happen the colls citlioi como to a
standstill, killed hy the intensity ot the poison,
and form a ring ot pus suri winding the focus
of infection, 01 \\heie tho poison is less intense,
tho whole of tho infected rogion is invjuled by
tho white-celled exudation
Tho uiitativp <t(tion ot the toxnu's spieads
beyond the coined to the iris and cih.uy Ixxly ,
these become hypoi.ennc , the blood-vessels of
the ins enlarge, the ins tissue becomes s\\ ollen,
its fibies hi mi ed, postcnoi synet hi.e ma} foim,
mid from the surface of the ins and angle? of
the antenoi chambei an exudation is poured
out which sinks to the l>ottom of the c hamber
and foims a hypop^on This hypop\on con-
sists of a hnrmons exudation with leueo^tes,
and is geneially fluid, so that its upper limit is
horizontal, and its position >anet> \\ith that ot
the head A h)popyon is steiile except when
the antenoi chambei has been opened, when
it may become infected tiom \\ithout The
opinion was fonneily held that the hypopyon
Mas den \ itl directlx from the seat of nlceiation
in the cornea by the passage of the products
of inflammation thicmgh Descemet's mem-
brane into the anterior dumber, the active
resistance of this membiane and of its ondo-
thehum lendei this manner of <iccess to the
antenoi ch.uuboi impossible The hypopyon
ma} sometnnes be seen extending up to the
legion of the ilooi of the ulcei as a yellow
coid communicating at its lo\\er end with the
geneial mass of the hypopyon At the hist
view this would appear prooi of a communica-
tion between the base of the ulcei and the
chamber, but examination of the piotess nmio-
8copu.illy shows th.it the corneal layers neai
the ulcei become swollen, the ondot helium
shanks in this spelling, some of its cells ex
foliate1, and a deposit of coagulated lymph and
cells foims on the denuded surface, which by
me ieasc« comes to communicate with the geneial
body of the hypopyon This condition is some-
times desciibed as postenoi abscess of the
cornea , it veiy frequently ends in a perfora-
tion of Doscemet's membiane, but in then
earlier stages the c-ells ot tin1 posteiioi abscess
aie stenle and heimentl} sho\\ thnr oiigm
from the n\ea in containing pigment
Result* of Ulrerative Krratitis — It the seat of
the nicer be in the substance of the cornea itself,
and the proper comeal tissue be destioyecl, a
pci nianeiit opacity results , the new scai tissue
cannot acquire tho pecnhai tianspaieney of
proper comeal tissue, although the scars and
blemishes left by ulcers in early life may to a
great extent disappeai Such opacities are
called nebula?, macuhr, or leucomnta accoidmg
to their density
If the loss of corneal substance is considerable
the intraocular pressure may cause tho floor of
the ulcer to bulge At hist Desccmet's mem-
brane being very clastic and resistant does not
give way, but forms a henna at the seat of
ulcei ation , the appearance of such a hernia is
that of a transparent bead on the coinea Tho
protrusion may flatten and become consolidated,
or it may pei for.ite , pci f oration is usually accom-
panied by .1 reduction of pain and imtation in
the e\e, but its results may be serious The
ins may come into contact with the back ol
the ulcer, or it may be piolapsed thiough tho
perfoiation If the ulcer then heal, an adhesion
of the iris to the back of the cornea will be loft
varying in thickness from a few filaments to a
bioadbaiid ol ins substance, nntrrwt synethta
If after perforation the lens come into contact
\\ith the baek of the inflamed coinea, an opacity
is formed at the anterior pole of the lens, and
an anterior polar or pyiamid.il cataiact results
The cornea sometimes heals with much loss of
substance, being then too weak to lesist the
pressure ot fluids within tho eye it bulges irregu-
larly and forms an antenoi staphvloma, this
also occuis after total destruction of the cornea,
the place of the cornea being taken by a thin
1,1} ei of fibious tissue united with the tissue of
the iris. This weakened membrane may burst
and collapse, and become peiinaneutly flattened
and consolidated, 01 it may yield again, and
again buist At tho time of its distension it
piotiudes between the lids like a button, and
is a souice of much distiess, after collapsing it
again ceases to gne trouble foi a time After a
large peif oration it is not uncommon for tho lens
to escape, for the wtieous to become prolapsed,
and for the globe to suppmate 01 to undergo
slow shrinking
Causes — Infection of the coniea by nucio-
oigamsms is necessary for the pioduction of the
ulcerative process , m most cases this is preceded
by a loss of suilace epithelium This may be
the lesult of an injiii} such as an abrasion of
the surface 01 the entrance of a foreign body ,
thus it ih common among men exposed to injury
horn then ti.ule, hut it also occuis as the lesult
of a wound, as by a baby's fmgei-nail, some of
the worst cases aie among agncultural labourers,
those engaged in hedge timumng, or especially
among those at woik in the hai \est-fielei In a
consideiablc number of cases mucocelo 01 chronic
inflammation of the lachiymal sac is present, and
this w ith its decomposing contents offers a con-
stant danger of infection to an unsound coniea
Ulcei ative keratitis may also occur horn infec-
tion ot the small ulcei s dunng an attack of
phl)< tenulai disease, or in a hcrpetic eruption
on the cornea The cornea may become infected
during gonorrhuial conjunctivitis, when the whole
of the epithelium is sodden and diminished in
utility, also where the nutrition of the cornea
as a whole, and especially of its epithelium, has
been profoundly altered, as in kerato-malacia.
Finally, ulceration of the coniea may take place
230
CORNEA
as the result of a blood infection, as is sometimes
seen during an attack of smallpox, when pustules
not infrequently develop on tho cornea itself
Paralysis of the facial nerve, leading to weaken-
ing of the orbiculans muscle and to insufficient
protection to the cornea , conical anesthesia
depending on fifth-nerve paialysis , the insensi-
bility of the cornea in absolute glaucoma, and in
the late stage of exhausting diseases such as
cholera, may lead to a loss of surface from ex-
posure, or from unconsciousness of the presence
of a foreign body
Treatment — Before beginning treatment the
cause of the ulceiative process should as fai as
possible be sought foi Foicigu bodies should
be removed from the coincti and the conjunctival
sac, misdnected eyelashes should be pulled out,
and the condition of the Uchiymal puncta should
be noted If the corneal affection is secondary
to disease of the conjunctiva, tieatment of the
latter should be actively pursued , in gonorrhccal
conjunctivitis the nitrate of silver ticatment
should be can led out as long as the condition
of the discharge rcndeis it iiecessaiy, tare l>eing
taken to prevent injury to the cornea by the
applications or by the necessary c\eisions of
the lids A mucocele 01 lachrymal abscess should
bo sought for, as this probably more than any
cause tends to keep up activity in an ulcci , the
lachrymal sac should be opened, and its contents
washed out daily, the passage into the nose
should be made free, and if necessary a style
should be insetted in the nasal duct
In most cases of ulcer of the cornea great
benefit will be dciived fiom the fit in application
of a compress to the eye, it greatly prevents
movement of tho lid and the constant winking
and spasm \\hich .tie so painful, and it ensuios
warmth and piotcction, the eye should be hist
covered with a pad of cotton -wool and the
bandage should be applied over it Where
there is much conjunctiva! secietion, as in the
cases of abscesses secondary to purulent con-
junctivitis, it is best not to bandage the eye,
because of the dangei to the cornea of keeping
the infectious discharge pent up between the
lids.
Heat applied to the eye is a valuable means
of treatment, especially when the general level of
nutrition is low The most convenient method
of applying heat m by hot bathing , simple hot
water, or better, hot saline, containing 1 per
cent of chloride of sodium, or a solution of 2
per cent of lx>ric acid, should bo applied to the
eyes by pads dipped in the solutions kept as
hot as they can be boine, this bathing should
be kept up for half an hour at a time, and
should be frequently repeated A good way of
keeping the lotion hot is to insert the basin in
which it is contained in a basin of very hot
water which can bo frequently renewed A
means of applying heat that is very valuable
is a Japanese hand-w aimer, a small oblong tin
box containing a slowly burning caitridgo, if
this be applied to the eye by a bandage over a
layer of cotton wool, tho heat can be kept up
without difficulty for any length of tune.
Caution must be mentioned here against the
use of any lotion containing lead where thcio
is loss of the corneal epithelium , an insoluble,
densely opaque film oi lead salts may be de-
posited on the ulcerated surf<ice
Atropine should be used so that the pupil
may bo kept fully dilated, iritis is picsent m
many cases of conical ulceiation, and atropme
is necessary, to prevent adhesions and to subdue
the iritis, apart fiom tins, howevci, ati opine
secures physiological rest of the eye by dilating
the pupil and paralysing the ciliary muse IP
The best means of using atropme is in ttic
form ot an ointment oi the strength of foui
giams of the alkaloid to the ounce of vaseline,
a small piece should be inserted inside the lower
lid twice a day, oi more often if nitis is present
The ointment is piefeiablc to drops, as it lemains
longer in the coujunctival sac, and acts more
thoroughly on the eyo, with less risk of the un-
pleasant symptoms oi ati opine poisoning fiom
its absoiption into the system A ti opine should
bo used just snfhuently to maintain full dilata-
tion of the pupil, it should not be sme.uod fioely
over the lids , sometimes \vhoie its use has boon
too profuse or too long-continued it gnos nso to
a highly eongostod state of the skin and con-
junctiva, a condition known as atiopmo mita-
tion A ti opine irntation occurs genoially in
those who aio peculiarly susceptible to its
a( tion , in such people the smallest amount gives
use to symptoms Whoie much redness of the
skin and coujunctnal nutation comes on dining
the use of ati opine this fonn of nutation should
be boino m mind, othci \\ise it may be thought
that the ulcci is woise and needs more ati opine
The drug should be discontinued and some other
mydnatic, such as sc opolanmie oi diiboisine,
should bo substituted for it li iiecessaiy, but it
is bcttei to discontinue all mydnatic s and use a
simple ointment of bone acid ior tho irritated
skin It is sometimes useful to combine lodo-
iorm with the atropme in infective ulccis
Atropine 4 gi , lodofoim 5j, vaseline, §j
Ewnne lias been stiongly iccommcndcd by
some surgeons as a routine treatment foi ulcers
of the cornea Where there is a possibility of
perforation it has undoubtedly a valuable place,
but, speaking generally, its use tends considci-
ably to the increase of irritative symptoms, pain,
and intolerance of light, and to the circumcoineal
congestion and iritis It should be lescrved for
those cases in which imminent danger of a per-
foration of the cornea leads to the fear that an
extensive prolapse of the ins may occur Ksenne
is also of value in certain cases in which the ulcer
is indolent for a long time, neither advancing
nor healing — a condition depending, probably,
on impairment of nutrition The increase of
CORNEA
231
vabculanty in the neighbouring parts induced
by Cberme piouiotcb the nntiition of the coniea,
the ingrowth of blood-vessels, and the healing
process in the ulcei It may be ubed .is an
ointment, 01 .ib diopb in the strength of one or
two granib to the ounce
Where the ulcer IH progiebsivc, with an
advancing mfiltiated edge, thebe measures arc
insufficient , rceoiusc must be had to the actual
umtery 01 to strowj caustic «jtj>lnyttioHt> to the
beat of the ulcer The cautery is mobt con-
veniently applied by a flattened loop of platinum
\vno bent to a convenient angle, and laibcd to a
dull-red heat by a galvanic cuiient The ulcei
being stained with fluorescine all the paitb whit li
take on the btam bhould be buint, especially
\vherc the infiltration ib densest , it ib not neces-
sary to burn the whole suifaee of the uhei, the
part that is healing and cov cred with eiidot helium
w ill not stain, .ind should not be touched
If tin* galvanic cauteiy be not available, a
Mnall Paquelm's or a metal cautery 1 Rated in
a spn it-lamp may be used, but these aio imuh
loss handy If the tcmpeiatuie of the wile be
not gieater than a dull -ml he.it the cauteiy
does not piixlucc effects beyond the pai ts actu.illy
touched by it, if the thin base of the ulcei be
poifoiated the incandescent wiie is at once chilled
by the escaping aqueous and no haini ic suits
For most advancing ulcers tieatment by stiong
local applications it, enough , the ulcei should bo
stained, the infiltiatcd jkiits should be s<iapod
with a small shaip spoon, .mil a (amd-h.ui brush
dipped in the 11 1 ud should lie painted o\ei the
stained surface, and mtioduced into all the
pockets and icccsses ot the ulcei Of these
caustic applications pine < at bolic acid is one ot
the most efficient and least pamiul , \vheie it
touches the* coinea the tissue1 is .it ome \\liitcncd
and aftei waids cast off, so that it should not be
applied caielcssly 01 111 excess Other agents,
such as nitrate oi silver, 10 grains to the ounce,
perchlondc ot mcicuiy 1 or 2 pel cent, 01 tinctuie
oi iodine, may be used, but the pun from them
as a inlc lasts longci and is moie seveie than
after caibolu acid
Be foi e using any of these methods of tieat-
ment the eye should be thoioughly cocaruscd
and a speculum intioduccd , as immobility of
the oye is veiy ebbcntial, a small amount of solid
cocaine in fine po\\dei may be applied to the ulcei
and also to the conjunctiva where it is giippcd
by the fixation foiceps After cauterisation
atropmc ointment or atropme ointment with
jodofoim should be used, and a compicss
Section oi the base ot the ulcer, opening the
anterior chambei, a method originated by
Saemisch, is a very valuable treatment where
a hypopyon is present, or when there is risk of
perforation A Graefe'b knife is passed into the
anterior chaining at one side of the ulcer, acioss
the chamber to the othei side, the cutting edge
being directed forwards, the knife IH made to
cut its \\ay out, completely dividing the base ot
the ulcer, opening the antcnor chambei, and as
a rule causing the escape of the hypopyon This
bhould be done blowly to avoid the sudden escape
of the aqueous, and with it piolapsc of the iru»
and possible damage to the lens
It is sometimes advisable to keep the wound
open foi a time in the eyent of the ieappeaiance
of the hypopyon , this may be done by inserting
a binall probe tat* con the lips of the wound
daily
A icccntly piolapsed ins may be icplaced,
but it is gcncially safei to remove it, it should
be bfi/ed, heed fiom the edge of the ulcei all
Kiiincl, diawn slightly foi ward, and cut off at
the level of the coinea The cut ends will then
cither retract or may be icplaced, but it ib seldom
possible to avoid adhesions of the HIS to the
wound
HiitMOHjunitiwil injcdwns of vmious anttsejitu
fluid* have been strongly lecommended by some
smgcons foi the treatment oi coineal affections,
ami especially of the diflereiit foims of infective
ulcer , perchloiide and cj.mido of meicuiy have
been used most frequently Moic recently, how-
cvci, it has been found that btenhsed saline
solution, 0 7.") per cent of chloride of sodium,
miccted beneath the conjunctiva is equally \ibc-
ful and less initatmg Enough is injected to
produce a moderate dibtcnwon of the loose con-
pmctna all lound the comua, there is a certain
amount of iea< tion aftei the injection for About
twenty-four houis
This ioim of tieatment has not found much
favour in this country and is now less spoken
of even by those who tust used it
In dealing with perfoiations of the coinea in
which the nis is entangled, theie is fiequeiitly
a difficulty in obtaining a firm cicatiix, the
involvement of the irib leaving unsound bpongy
tissue In sonic cases a fistula is foimed, in
othei s the coinea ovei the seat oi the perfora-
tion le mains thin and bulged for an indefinite
time, the nsk oi septic inoculation of such an
ej e is considerable Complete rest in bed, avoid-
ance oi movement and use ot the eyes, a com-
piess ovei the damaged eye, the other one being
also bandaged, are means by which sounder union
may be seemed Ksenne has been lecomineiided
to keep down the tension of the eye as much as
posbible, but theie is little or no evidence that
esenne reduces the tension except where it has
been prev lously raised
A method of coiibideiahlc value in securing
him cicatribation is the tnmy&tntiition of icw-
junctwa to t/te wif of the ulctt
Aftei freshening the suifacc of the damaged
coinea 01 the edges of the fistula, this may be
done in the following way — A flap of con-
juncti\a ib dissected up, being left attached by
a pedicle , the flap is twisted on itself and tucked
into the weakened spot anothei method is to
dibbect up a budge of conjunctiva at the upper
232
CORNEA
part of the globe, leaving the two ends attached,
bringing the bridge down to the seat of the
ulcer, and tethering it by one or two sutures
applied to the conjunctiva at the edge of the
cornea ; it may also be done by dissecting up
the conjunctiva all round the globe, and bring-
ing it together by continuous sutuic at itb fice
edge, thus covcimg the whole conica
The conjunctiva seems to act in two ways,
partly by the support which it grves to the
cornea, and partly by becoming adherent to the
seat of the ulcer The fact of the cornea being
covered by conjunctiva does not seem to give
trouble, aftei the sutures come away the cou-
junctna falls back again to its propei place
Oxygen gas has been lecommended as a treat-
ment for indolent ulcers of the cornea , the
application is made by means of a closely fitting
cap, the oxygen being passed over the e} e in a
constant stream.
Treatment of the Result* of Cmn&il Ulcetatton
—Opacities — Little can be done for the treat-
ment of opacities of the coinea The use of
stimulants, like the yellow oxide of meicury
ointment, 4 gi to the ounce of uiselmo, 01 of
wine of opium, combined with massage, should
be continued for a long time Opacities due to
a deposit of lead on the coinea may be remo\cd
by scraping In some cases undoubted improve-
ment has followed the application of a gahamc
current directly to the coinea, but it is un-
reliable Tattooing is sometimes done, paitly
for cosmetic reasons and paitly tor the impiove-
ment of vision When the nebula paitly cove i,s
the pupil, or \vheie an aitihcial pupil has been
made opposite clear coinea, the dispcision oi the
light passing through tho nebula causes much
disturbance of vision thiough the clear part oi
the cornea Rendering the nebula dark by tat-
tooing it, may result in great impio\ement of
vision. The am face of the nebula is pricked all
over by a bundle of needles, and Indian ink
rubbed up into a paste is applied to the surface,
or a Wecker's giooved needle, containing Indian
ink in tho groove, is passed into the cornea
parallel to its surface, and tho ink deposited
in tho substance of the cornea, the operation
has to t>e lepeatcd se\eral times Too much
should not bo done at one sitting , eyes in \\ Inch
the cicatrised cornea is thin, or has the ms
adherent to it, should not be touched The pig-
mentation of the cornea so obtained is not
permanent
Transplantation of the conica is not yet w ithm
the domain of practical suigciy, for though the
operation has been done \vith success as regards
the life of the transplanted coinea, its trans
parency has never been maintained
TYPES OF CUKXEAL UWKKATIOK — The Simple
Ulcer. — Tho simple nicer may arise from an
injury to the epithelium, or from the intro-
duction of a foreign body into the eye It
appears as a somewhat laised grey spot, which
becomes a shallow crater with "some infiltration
of its base, there is cucumcorneal congestion,
pain, and intolerance of light.
Treatment — Hot fomentations, compress, and
atiopino (see general remarks on Treatment)
Infe(tive Ulcet — Tho ulcer heals rapidly as a
rule, but it may occasionally penetrate deeply,
and o^en peif orate the anterior chamber In
this case, instead of clearing, the base and
margins of the ulcer Ixjcome yellow with in
filtration, the surioundmg cornea becomes ha?y,
uitis is set up, and a hypopjon loims
This type of infectne ulcer is most (onimonly
seen during the comae of a pmuleut conjunc-
tmtis, but it may occui as the lesult of an
infection of the conical tissue apart fiom general
conjunctivitis Its tendency is to penetrate
deeply into the coinea, but not to spiead widely ,
in this tespect it differs iiom the seipisjinous
ulcer
Tttntment — On the snmo lines as that of the
simple ulcei, but more actne measuies, such
as caiefully applied caustics, 01 tho cauteiy,
may be necessaiy If purulent conjunttmtis
be piesent its actne tieatment should be pm-
sued
Cattnt/uil fleet • -Diiuiig .in attack of con-
junctival cataiih we sometimes meet with one
01 two louudcd 01 ciescentic ulceis near the
imugiu of tho coinea They usually heal
icadily During the later stages of tiachoma,
when pannus of tho coinea has been fonncd ami
the lid has eicatmed, it is not uncommon to see
small shai ply-cut ulcers with a dear base at the
edge of, 01 on the pannus itself , they generally
come with <i slight iccurieucc of nutation
in the lids In addition to the local treat-
ment of atropine the lids themselves lequne
attention
tieiint/infjru't Ulcw> — Theio aic se\eial kinds
of ulcei whoso tendency is to spiead into the
healthy parts in then neighbomhood , in their
whole coiuse the charactci of these ulceis m
distinct, the only common feature is their
tendency to spiead The main fonns aie — the
acute serpiginons ulcei, the maigmal ditch
ulcer, the lodent ulcer, and the dendritic ulcci
Some of these are descnl>ed now, the othcis will
be found in their place latei
The Acute Snpiymom bhei , Ulnu> ti&pens f
Hypopyon Kwatitis — This begins as a dirty
grey spot showing a loss of suifacc, with an in-
filtrated base and edges, the base is uneven,
and is covered with broken-down epithelial and
conical cells. It commonly follows a slight
injury, and occurs especially in those who ha\e
a diseased lachrymal sac The characteristic
feature of this foiin of ulcoi is its advancing
edge, which generally appears as a yellow
eieHcentic area situated at one edge of the
ulcer This ciesceutic area tends gradually to
spread ovei the cornea superficially in one
direction, while the part of the ulcer first formed
Ui*t
*»—
iifie 232
DISEASES OF CORNEA
Ulc«r i
CORNKA
533
remains stationary or tends to heal The
cornea around the ulcer is cloudy, there is
intense circumcorneal injection , a certain
amount of iritis is present, the ins is bliured
and swollen, enlarged blood-vessels may he seen
on it, and postcnor synedmu may be foimed
A hypopyon appears veiyeaily in the disease
The signs of nutation aie veiy gieat in most
cases, intense pain, intolerance oi light, some
fover, and a \vant of sleep , in othei cases the
signs of irritation aiu not maiked It not
checked the hypopyon inci eases and may fill
the anteiioi chamber, the ulcei spreads so that
a considerable aiea of the comca becomes in-
volved, and this eithei yields to the intiaoeulai
pressure and peifoiates, in the nlcci penetiates
deeply and the same lesult obtains In some
cases perf 01 ation is lolloped by genci.il infection,
pdiiophthalmitis, and total destruction of the
eye, but, on the othei hand, it sometimes maiks
the onset of a i emission of most oi the niitative
signs, and is followed by a tendency to »\ aids
healing. Abscess of the coined, is closely allied
to the scrpigmous ulcei, but it spieads in the
substance oi the roinea without destining the
surface, if it is seated in the superficial labels
the greater pait of its antenor \\all \\ill bicak
down and ioim an ulcei, but it may nnade the
deeper lasers and 11111 its whole couisc without
destiojing the suiface It is generally not
veiy at ute, but it is frequently accompanied bv
uitis «md hypopjon, 111 some of the \eiy
chrome (ases the mass oi exudation does not
go on to active suppuiation, but quietlv sub-
sides, and is eventually tiaiisfoimed into tibious
tissue
Ttfiitntfnt — Fomentations and atiopme in
the eaihcst stages, with a compress, followed
by the galvanic cauteiy or the local applica-
tion of carbolic acid, 01 some other caustic,
Kaemisch's opeiation on the ulcei , the treatment
of any lachrymal sac complication (sec gcneial
remarks on Tieatment)
Tlte Mnrt/imd Dittlt 1'?<tr Mntifinnl Runf
Vlcet — This begins ,is a t»ioo\c ne«u the edge
of the coinea, it is usually rathei deep, with
sharply-cut edges, with 01 without initiation
of its base , its tendent y is to creep gradually
lound the edge of the coinea, but it may heal
in one pait while ad valuing in anothci , if not
checked the whole cornea may be destroyed by
it. It generally occurs in old people with failing
nutrition , the cause is not known
Tieatment — The galvanic cauteiv should be
applied to the advancing edge of the ulcer
Kscrine should be used to improve the local
nutntion as well as heat and compresses
The Rodent Ulcn — A giey infiltiation appears
at the penpheiy of the coinea and soon bieaks
down into an ulcei , the ulcei does not pene-
tiate deeply, but tends to spread slowly and
intermittently over the whole conical suiface
The appearance of this foim of ulcer is quite
peculiar and characteristic The surface of the
ulcerated ai ea is below the level of the rest ot
the cornea, it is uneven and opaque, and may
contain blood-vessels w Inch have spread in from
the hmbus At the line of junction with the
unaffected pai t of the cornea, the latter stands
up coiisideiably above the ulcei ated aiea, and
has abiupt clift-likc edge/i which are grey in
coloui and undermined in places The piogress
of the ulcer is \eiy slow, and it has peuods
of quiescence, but it eventually (icepsovei and
spoils the whole suiface of the cornea It
occurs chiefly among eldeily people, and especi-
ally among those who have lived abioad, but it
is a very uncommon form of ulcei The only
tieatmcnt .it all efficacious is to cauterise the
ddvancing giey edge of the ulcei
Keiato-AIyrow* AymvtjitliiHi — This r«nc aftcc-
turn has been desciibed by several Continental
I w liters, but no case has hitheito been reported
111 this couutiy It is due to the giowth on the
(oinea of the fungus Aspeiuillus fumigatus,
which gains an enhance bj means ot a foieie;n
body or other mjurj to the coineal epithelium
The fungus appeals as a giev mass with a dr}
ciumblmg surface, seated generally near the
eentie of the coinea, the sinus of nutation are
not M'veie, and the ionise of the affection is
tedious The mass of the gtouth i,s, as a rule,
cast off by exfoliation of the part of the cornea
in which it has been glow ing Its icmoval may
he hastened b\ sti aping
Tnhl'Hivr IENUI AK UK i- it (J'/tlyctennlin con
junctivttti, Pu^tulat loujunctiiHtii, Emnthfmm-
tnv& m ec-ematowt (onjunttiviti*, Phlyitrnulm
oi jwstu/m keinMib, A/int/imif Aetattti*, /A»/>es
. of the cwnm, Snofulons <n \tntmmn oj>/it/ialnnat
Lym2>h<itu tonjunt ttvitt*)
This disease appeals in a gieat \atiety of
ioims, eachot which hasdifteient stages , neaily
all the ioims and stages have iecei\ed se]).irate
names the icsult has been the unnecessaiy
complication of a \ei} common aftection The
disease is inainl) one oi childhood , the general
t\pe consists in the ioimation ot a limited
exudation ot hmphoid cells beneath the epi-
thelium of the cornea oi eonjunctna , the
epithelium bieaks down, leaxmg a small shallow
ulcei The ulcer lemams for a time, but is
giaduall) icpaittcl by epithelium cieepmu; over
its binfcue, at the same time a snnilai uliei
has been ioimed elsewhere, sometimes the ulcers
aie \n$ minute, and aio known as iiulmiy
phl^ctenul.e These aie often so rumerous as
to un.uie the whole hmbus, and e\eu to be
scattered o>ei the whole surface of the coinea,
which has the appeal auce of being covered with
minute giams ot sand The irritative sj mptoms
aie severe, the coujun<tn«i of the lid is much
swollen, there is intense tear of the light and
spasm of the lids, the outer canthus is frequently
cracked 01 exconated, the child shrinks away to
the darkest coiner and keeps his face deeply
234
CORNEA
buried. At the slightest attempt to open the
eyes a copious gush of tears comes out, and it
is well-nigh impossible to obtain a view of the
cornea Thobo confluent phlyctenuldj produce
a swelling of the limbus, while the cornea in the
immediate neighbourhood loses its transparency,
and contains a number ot small grey points
just beneath the epithelium With bmall
phlyctenul.u, as a rule resolution takes place,
the elevations disappear If they break down
into an ulcer by loss of the covering epithelium,
the nicer as a rule heals, but it may become
infected and take on the characters of an in-
fective ulcei (sec p 232) In other cases the
behaviour is quite diffeicnt the ulcei assumes
a chronic com he and may remain stationaiy for
weeks, vessels glow into the cornea fiom the
limbus towards the crater-like depicssion, and
healing takes place slowly The healing docs
not always follow the ingrowth of vessels , the
ulcer slowly pushes its way towards the centie
of the cornea, canying the leash of blood-vessels
with it Thw condition is known as a LeaJi
ulcer or fttvctcular keiatttis The advancing
edge of the ulcei is convex towards the centre
of the cornea, and somewhat raised in the form
of a descent, consisting of an exudation into the
conical substance, the* vessels ot the fasciculus
ending in the concavity of the crescent The
difference bet\vocn this leash ulcer and the
natural healing of an ulcei by an ingro\\th ot
vessels lies in the fact that the leash ulcei < 011-
tams a yellow edge of purulent exudation This
condition may last weeks or months, and icsults
in the formation of a Uind-like ojucity \\hich
remains visible foi \eais
Whcie the ulceis of the cornea aie multiple
and adjacent to one anothei the ingrowth of
vessels of icpair from the limbus may occupy a
considerable aiea of the coinea These vessels
remain as potential blood-channels for a \ery
long time after the complete healing of the
ulcer, and ate liable to become easily congested,
giving use to a condition known as phlyr tcnular
pamms, 01 superficial vascular keratitis The
vessels lie beneath the epithelium , at times
they aie invisible except to careful examination,
and at others they aie much enlarged, and the
conical surface is lough and uneven
(Jaumtwn — This is u disease of childhood,
but it does not occur generally in children under
one year old , its most common penod is from
two to sixteen years, during this time skin
eruptions, eczema, and impetigo about the face
aie very common, togethei with a similar con-
dition of the nasal mucous membrane It most
commonly occurs when the changes m tempera-
ture are great and sudden, as in spring and
autumn , as the effect of climatic changes is
greater among people who live m damp, ill-
ventilatcd, or overcrowded houses, so this dis-
ease is common among the poor, and rarely
occurs in children whose surroundings are satis-
factoiy As a probable result also of environ-
ment the child i en fall into n regular habits of
feeding, and eat anything at any odd time
instead of having tegular meals, wheieby the
appetite becomes capricious and the desire for
unwholesome food is established
The next most common exciting cause is a
previous attack of some acute exanthematous
disease, such as measles, scailet fevei, 01 whoop-
ing-cough, by far the most common of which is
measles The eye affection comes on a tew
weeks after the measles, and is not the same us
the conjunctival inflammation which commonly
ushcis in the first stage of measles The nnta-
tion of head lice is a frequent a< compannnent of
the dise.ise, and is especially likely to occui, as
during this period the childien appeal sufficiently
morose and unatti active to make neglect piob-
able
It is held by many that this affection is in
its natuie strumous or sciofulous The old
term Sciotulous ophthalmia, besides including
all the eye affections ot this gioup, was applied
to all cases in which theie was ex ti erne mtolei-
ancc oi light, it was thought that the photo-
phobia was induced by an nutation of the optic
nciNC and retina, and a consequent icilex spasm
of the orbiculans, but inasmuch as ticatnieut
applied to the tei initiations of the fifth nei\c in
the (oinca and conjunctiva leads to diminution
oi the intolerance of light, we know that the
affection is a supciticial one only , the intoleianco
is not gietitei than may be pioduced by A
foreign body undei the upper lid It is chai-
atteiistic ot all cases of supeiticial kciatitis in
the glowing penod of life that nutation, mtolci-
ance ot light, and spasm of the lids aie much
1 gieatei than in adult life Yet the tenu stiu-
mous or suofulous ophthalmia has this justifica-
tion, th.it in .1 laige numbei ot cases of superficial
corneal inflammation in the young theie is a
ceit am condition of the tissues which makes
them favouiably disposed to the occunencc of
inflammatory outbreaks which aie veiy chrome
in then couise, and which tend to recur without
obvious cause
i This condition is associated with a pi oneness
I of the lymphatic tissue in the body to hyper-
' ti ophy, the glands in the neck or at the angle
, of the jaw become enlarged, the mucous mem-
| hiaiic of the nose becomes swollen and inflamed,
and masses of adenoid tissue form in the
pharynx Also if the family history and ante-
cedents of the parents be carefully examined
theie will be found a liability to tuberculous
affections in others of the family Evidence of
this sort has to be received with caution, as it
I depends on the statements of friends who are
i often anxious to pioduce what they think the
1 inquiier is seeking to find But the liability to
| recurrence of phlyctenular disease, its associa-
tion with other lymphatic hypertrophies, the
I frequency of its appearance in more than one
CORNEA
235
member of a family, point to <i peculiarity in
the tissues capable of being transmitted horn
one generation to .mothei, and favourable to
the growth of eeitain organisms The actual
iclationship with tubcicle is probably no nearer
than thin phlyctenul.e have been excised and
examined frequently \vithout leveahng the
presence of anything but staphylococci , tubercle
bacilli have never been found
Tieatment — This should be local and general
Locally a little bone add lotion, ten giams to
the ounce, should be dropped into the eye about
three tunes a day , if theie is any photophobia
or spasrn oi the lids atropine should be used
night and morning It is necessaiy to get a
view of the toinca — often a inattei of difficulty ,
this tan geneially be done by some coaxing , it
may be necessary, however, to use lid letractois,
or even to give an anaesthetic to get a \ie\\ In
many of the cases in vshich the spasm of the
lid is greatest the involvement of the cornea is
only tmial It is often possible to obtain lehef
of the spasm by the sudden shock of cold \\atei
falling on the face horn a sponge held above the
patient , or if the spasm is gieut and the < orneal
involvement small, it IH useful to cvcit the lids,
diy the conjunctiva, and apply to it heel} and
to the skin of the lid, especially if ee/ema be
present 01 the can thus be < racked, a solution of
uitiate of silvci, mopping up the excess , a few
horns aftei the application the thild sometimes
spontaneously opens the e\os Whui the stage
of nutation has passed, yellow oxide of men uiy,
four giains to vaseline one ounce, may be used
for a considerable time
The fascitulai fin in is veij tedious, if the
ciescentic area is )ellow and .ulvancing it must
be cauterised, 01 scraped and touched with
carbolic acid, or with the point of a stick oi
mitigated nitrate of silvei
As a rule it is bettei not to bandage the eyes,
coolness, free access of an aie good , to piotect
the e^es from light, goggles 01 a shade may be
used , bleeding and blisteis are useless and
harmful, a seton m the scalp is a veiy active
remedy in cases which icsist all othei kinds of
tieatmeiit, but it is liable to set up t elluhtis of
the scalp with suppuiation in the neighbouimg
glands, so that it should only be used in those
cases in which all othet methods have failed
As to genet a/ treatment, it is well to begin
with a purge followed by non, aisemc, 01
quinine and cod-liver oil or cream as an addition
to the diet, regulation of the horns of feeding,
the fen bidding of cakes 01 uniipe fruit between
meals , a change of aii to the country or seaside
w moHt beneficial , if this cannot be secured, the
child should be made to live in the open air as
much «i8 possible The local skin affections
should be treated, adenoids removed, and dis-
infection of the nose and throat seemed
AFtbCTlO^ Of THE CuKMA ASSOUAN I) Wllll
Tiih FOUMAIION M Jiuu f. — Jfetpe* of the Ctnnm
— This affection appeals under two forms,
simple febrile heipes and the more severe herpes
/ostcr
Febrile herpes occurs chiefly in childien
dm ing a iebnle att.uk, such as e\anthematous
fevei, pneumonia, 01 even a catairh of the re-
spnatoiy or nasal passages Jhiiing the eaily
stage1 theie aie intense photophobia, spasm of the
lid, and lachrymation , one or more minute
blisteis fotm on the surface of the cornea, and
v\hen seen some of them may be entne, contain-
ing fluid, or moie geneially they have binst,
and \\e see a shred of epithelium attached to
the edge of a shallow pit in the toinea The
bill la* may be ai tanged in line, 01 they may
form a constellation in one pait of the cornea ,
the edge of the pit is quite cleai and sharp, and
appeals as if a piece of the cornea had been cut
out by a spud or finger-nail The healing
generally takes place as in an oidmary ulcer
after the shedding of the epithelium The
sensibility of the coinca is said to be lowered in
the legion of the blisters, and the tension is also
said to be i educed , it is dithcult to apply satis-
factoiv tests in the condition of nutation
piescnt, but the tension is not al \\ays lo \\eied,
and the coinca is sometimes hypci<esthctu ,
these may vary m the diflcient stages of the
affection Febrile heipes is only chaiactciislic
in the eailicst stage, when it is not often seen ,
.it a latei penod it cannot be distinguished
horn a simple or phljctcnul.u ulici
TirttttntHt — Kest, shade foi both eves, atio
pine, and geneial tie.it men t of the catarrhal
state aie measuies geneially enough to heal
the uleei vvithout leaving a mark, but it may
become nifcc ted like any othei ulcei (see geneial
icm<uks on Tieatment of I 'leers of the ('oinea)
//<//« s osfe/ of the unma occuis as pait of
heipes /ostei ophthalmic us, an inflammation of
the fust division of the fifth nene 01 (Jassciian
ganglion Wheie the supia-oibital or supia-
tioc hleai blanches only aie affected the coinea
as a inle escapes, but v\hen the nasal blanch is
involved, shown by the spots oe< lining on the
tip of the nose, theie aie geneially iilcciation of
the corm-i, nitis, and sometimes cvchtis, the
nerves of the fioiit of the eye aie dcnved fiom
the nasal bianeh of the fifth nerve by way of
the long loot of the lenticular ganglion The
heipetic attack is picccded bv intense nemalgia,
pain and swelling of the lid , this latter is so
gieat that the affection is often thought to be
erysipelas , one or two vesicles appeal on the
coinea and form ulccis, in spite of the intense
pain the cornea is as a iuli» completely anes-
thetic, and may remain so foi a long period
The lifntmtnt of the ulceiation is that of a
simple ulcei, but it must be Inane in mind that
the cornea is insensitive and cannot protect
itself against foreign bodies and other kinds of
injury, so that it must be bandaged and care-
fully watched
236
CORNKA
The dendritic ulc?r is a well-defined variety of
superficial cortical ulccratiou It is generally
seen as a groove in the cornea counting of a
central stem with small buds or blanches at
each aide, the ulcer has a tendency to creep
over the coinea and spoil a large pait ot the
surface The ulcer sometimes occupies the
centre of the cornea, but in the most chai-
actenstic cases extend-* fiom the hmbus as a
broad trunk which gives off branches on each
side, the blanches themselves ending in secondaiy
branches or buds In its eailicst foimation the
affection is hurpetic in chaiacter, the buds have
the appearance of small bull.'c The appearance
of the dendritic ulcer is very stiikmg and Iwau-
tiful aftei staining with iluotescmc
It is not known \\hat is the cause nr exact
nature ot the dcndutic ulcer, but it piobably
l>elongs to the herpetie group, it occurs fie-
quently in people who have been subject to
nialaua, and has been dcscubed as mttkmal
kewtotii, but in this country it is seen not
seldom in patients who have nevet been abioad
and who have never had any torm oi malaria
It occurs in those \vho aio past the best ponod
of life, or who are tempoi -inly HIM down, [
have seen it t\\ice in young childien, botli of
whom were much exhausted by piolonged joint
huppuiation
Treatment must be radical The com be of
tho ulcei is larely stopped by the ordmaiy
routine measuies, such .is tomentations, atropme,
com pi esses The galvano-c'auteiy at a vei> low
tempeiatuie may be used, but thete is risk of
producing a pcimanent scar with it, carbolic
acid is satei and bettet, but several applications
are often needed Tho most effective tieatment
is absolute alcohol applied by dipping a small
loll of lint into the alcohol and nibbing the
ulcerated surface with it, the epithelium foi
some distance .uound the ulcer is tcmoved, but
it is quickly icgenetatcd Tho only drawback
to this very efficient method, which we owe to
Svvan/y, is its pamtulness
An affection closely allied to fubiilc hcipos is
the sujwfiddl punctnte hetaUtn (Fuchs) A
numbei of small giey elevations appear in the
cornea anangcd like febrile heipcs in lines or
constellations, their number may vary fiom
ten or twenty to about a hundred, grey lines
are also seen in the coinea, which arc probably
caused by exudation into tho conical nerve
ti unks. There is much photophobia, although
tho cornea is somcw hat amcsthetic The attack
is part of a general catarrhal condition affecting
the parts supplied by the fifth nerve , the nota-
tion cleat s up in a short time, but the giey
spots may temain for months
Lwil Tteatmrut — I'totection from light, and
atropme (sec genet at rematks on Ticattuent)
Reciment Jiut/om Keuititi* — A solitary
blister sometimes forms spontaneously under
the corneal epithelium, attended by severe
neuralgia, mtolctancu of light, and vvatoimg
Sometimes there has been an injury at the spot,
and for a time iccuricnces take place in the
same eye, but the affection is often independent
of injiuy, and the t elapses occur either at
definite times in the year ot at mtetvals depend-
ing on some vanation in health , in some cases
the attack always occurs at a inenstin.il penod,
though not at each one.
Treatment — liandagc, rest, ati opine, some-
times teat ing off the shred of epithelium left by
the bulla, causes considerable ichcf of pain
Quinine has boon advised as a pi ophy lactic, on
the assumption of a malaual basis, but it is not
possible to pi edict the onset of an attack
Bulla1 ate sometimes formed in eyes blind
fiom old glaiuoma, in which the cornea is more
or less devoid of sensation They also occui
upon old leucomata associated with a tempoi ary
mciease of tension, it may bo necessary to do
an indectomy fot the cute of the mucaso of
tension if the eye is wotth saving
Fihnifntmif Knntiti* is a xeiy rate disease
Numerous small threads ate seen hanging from
the sin face ot tho coinea and attarhcd to it
quite finnly The thieads consist of a twisted
stiand of epithelial cells hav ing a bulbous end,
and coveted in places by mucus \\hen the
threads drop off the base heals, but their place
is taken bj othets caused by dcgeneiation of
adjacent epithelium The tieatment consists
in lest, ati opine, and bandage
AAJMio-J/4/ u JA — Infantile Uh Mutton of the
f V>> nen — This serious atfe< tion occurs in young
childten \\ ho arc the subjects of giave distutbam e
of niitntion, due eithei to st.u vation ot improper
feuding, 01 to the exhaustion of disease The
hist manifestation of the affection is A diyness
of the conjunctiva and cornea, and the foimation
of a small tn.ingulat foam patch at the inner
and outet mait>ms of the coinca in the exposed
patt of the eye This lack of lustie oi diyness,
which varies gieatly in degtee, is due to a fatty
dcgeneiation of the epithelial cells, and a con-
sequent inability of the teuis to moisten the
surface
Local infection of the coinea thtough the
degeneiated epithelium is followed by deep
initiation and rapid destiuction of the whole
or pait of it , tho actual organisms piesent have
been found to be stteptococci ot pneumococci,
and the foam patches contain the xeiosis
bacillus
| During its whole course the disease is attended
hj very slight local symptoms, little or no dis-
charge, and scarcely any intolerance of light
Ketato-malacia is rately present without there
being grave distut bailees of genet al nutrition ,
the children, if not actually wasted, have an
unhealthy, ashen colour, they ate, however, foi
the most part greatl} emaciated by constant
diarthcea and vomiting, and in spite of evety
<aie thev die
CORNEA
237
Keratonialdcia appears 111 England mostly in j
hand -reared infant* badly wmiibhed in conse-
quence of unsuitable food 01 oi piedongcd
diarrhcua. Poorness or insufficiency of milk, the
use of condensed milk from \\lm-h the u earn has
been separated, the use of patent staich foods
in the place oi pine milk, die among the most
common causes, but it mayocciu in hand-ieaied
infante in the tailing of x\hom the nutiitive
value of the milk has been impaiied by pio-
longed or lepeated boiling being eauicd out
with the laudable desuc of rendering it stuiilo
One is reminded of the expcinnent of Majendie,
who fed a well-nourished dog on nothing but
putc xvhite sugai and \\atcr, with the lesult of
pioducing a <ential ulcer of the (oinea Sex ere
exhaustion aftei ac'iite fevers or pneumonia is a
predisposing cause, find is often seen in the late
stages of mild ophthalmia neonatuium in babies
sutfeimg fiom congenital syphilis In count) les
wheie lehgious fasting is stnctly obseixcd it
also occin s in breast-ted child ion
Tieatnient, both IOCM! and general, should be
directed tow aids improvement in nutiition
Warmth by compresses and hot fomentations
fioqiiently applied , the local use of eseime m
the tonn ot an ointment, one giain to the oinu <
tin PC times a day, are the best local mcasuies ,
while gencial tieatment should be in the
dim lion of seeming piopei food, milk diluted
accoidmg to age, cicam or cod-hxei oil, and
iue.it jiiKO, and the dianlura should be com-
bated
UntR \utix of nil C(iu\n IMU E*ro\vnr —
When the < ome.i is ex]K>sed to the ail it becomes
lapidly thy, and if not moistened by teais its
surface is destioyid and a \\ay pioxided foi the
e'litumce of oiganisms
This condition is piodmed by ucatnsation
and conti action of the lids iiom old mjuiy 01
disease, it ouuis in facial paialvsis when the
lowei lid no longei keeps in position , also in
the cxticme piotrusion of the eye sometimes
met with in exophthalmic goitie, and m oibital
tumouis It is also seen (lining the condition
of apathy in patients sufleimg fiom exhausting
disease
Treatment — The eye should be closed tempo-
lanly by a piece of stiappuig, but if the exposiue
is likely to be permanent, the edges of the lids
may be pared and stitt hcil together ioi a ceitam
distance
NtuiM-PAR ii y //( KhRAnri^ — >\ hen the hfth
nerve is paralysed the eoinea becomes uutChlhctip
and IB readily exposed to injuiy , foreign bodies
are not swept away, and the suifacc is no longei
kept moist by the mo\ements of the lids induced
by the sensations of the eoinea The epithelium
becomes cast oft from a portion of the suiface,
and an ulcei is foimed , this form of ukeiation
runs a very chiomc couise, and is little affected
by treatment , infection may take place, and
the eye may be lost The changes have been
described as beginning mteistitially without los>
of epithelium
It is held by many that the paialysis of the
fifth nerve is associ.ited with a tiophic distmb-
ance in the eoinea, and although the results of
section of the hfth nei\e on the nutiition ot the
cornea tend to show that if the eoinea be pro-
tected such section has no influence on it, yet
if we take the analogy of othei parts, e y the
glossy skin which occuih in paralysis of
sensory neives, it is highly piobablo that the
fifth nei\e does exeit an influence on the nutii-
tion of the conic. i <'lmical evidence is in
fax out of this xiew
The tfvitHKnt is that of ulcei.itive keratitis,
especial taic being taken to secuie protection
ot the e\ e
/\//ffs/mi?i »A 7'i/j vn/i vj/ous KIRAIIIK
— In this dise.iso the deepei labels ot the cornea
are attacked by chiomc inflammation with the
formation of op.icities and with the development
of bltxxl- vessels The changes in the eoinea
show a tendency to cle.u up toi months after
the inflammatory symptoms have subsided,
theie is no tendency to ulcciation 01 suppma-
tion
The appeaiance of the changes in the eoinea is
pieu-ded by < iicunu oineal congestion, lachi jma-
tion, and mtoleiance of light, an examination
of the eje is made difficult by spasm of the lids,
hemcj in many of the xxoist cases it is not
posMble to sav what is the exact condition of
the eoinea The e hanges show themsehes in
many foims, but the most common mode oi
onset is the appcaiance at the peiipheiy of the
coine.i in one s]K>t of .1 gioup ot macuUe deep in
the coineal substance, the epithelium cox ei mg
them becomes swollen and losc»s its lustie, so
tliat the mac ul, u aie onlj sc'en dual) At the
same time the xessels ot the limbus become
much cnlaigcd .it this sj>e>t, and the limbus
itself is swollen and em loaches somewhat on
the sin face oi the coined in the tonn of a
xasculai crescent, this eneioachment does not
evecd ceitam nanow limits At the same
time, theie is an ingiowth into the coineal
substance of xessels coming fiom the deepei
Id) or of the scloiotic, appealing beneath the
limbus ,md haxmg no connection with its
xessels These aie long and thin, and die in
the substance ot the eoinea, they have the
appeaianee ot long tufts, and haxe been likened
to the fibies of a bewnn , they giadually force
their xv.iy into the substance ot the eoinea, the
area of macuhe still extending m tiont ot them
towaids the centie , sometimes the piocess starts
fiom two opposite* sides of the eoinea, the
sknmishing line of macul.e advancing towaids
the ce'iitre till they meet those coming fiom the
othei side In anothei gioup of cases, instead
oi staiting peiipheially fiom one or two ]x>mts,
the maculaj make then appeal anco towaids the
centre of the cornea, where they become con-
238
CORNEA
fluent, and from this region gradually extend
towards the margin, the cornea is almost
uniformly grey, the centre being more opaquely
grey than the periphery At the same tune
the epithelium is swollen and loses its
polish , with a magnifying glass 01 conical
microscope the individual (oils can be seen
unevenly owlematous Then1 aie varieties in
the amount ot vnsculanty picsent , in some cases
the vessels c?m be been singly, in others they
an* very mimcious and appear only as a pink
patch in the coinea, a condition kno\\n an a
salmon patch The density of the opacity %anes
greatly, <ind is, as a rule, patchy , at the height
of the attack the deeper parts of the eye cannot
bo seen with any < leamess, but, as a mle, it can
be made out that the anteiioi chamber is deep,
that the pupil is either not dilated hecly 01
that adhesions are present, and that theie is a
deposit on the back of the cornea, Aetatitts
jwmtiita, the wgn of involvement of the cihai}
body The tension of the eye is gencially rathei
lowered In older patients fioin the beginning
the corne.il opacity in its earliest stage some-
times takes on the stnatud foim, gioy lines aie
seen deep in the conical substaiNo, these aie
followed by the development ot a geneial ha/c
of the deepest layeis of the cornea
Intel stitial keiatitis is always chronic in its
comse, the opacity of the coinea and the in-
flammatory and irntativc svmptoms go on
increasing foi about two months, and then
slowly decline At its worst the vision is
much reduced, even to the perception of hand
movements As the attack abates the ciliaiy
congestion diminishes, the coinea cleais from
the periphery, and the sight begins to improve,
the clearing and improvement in vision < ontinu-
mg foi many months The se\erity of the
attacks varies very gieatly in younu children
it is not uncommon to see a few macul.e at the
periphery, or a slight cential luueo with Lilian
congestion disappearing cntnely in a very few
weeks, an attack in miniature only, on the
other hand, in the woist cases tho irritative
symptoms may last twelve months 01 longei,
and the coinea may be couveitcd into a dense
white tendinous stiuctuie absolutely opaque
It happens laid) that the cornea yields owing
to inflammatory softening and becomes bulged ,
this is sometimes uniform, and may subside
without causing any gioss change in the conical
curvature, at other times tho Melding of the
cornea may be preceded by the ion nation of a
gumma of the cornea, a local mass of granulation
tissue simotindod by a dense felt of vessels, and
having a tendency to degenerate at the centre
It is very uncommon foi an abscess or ulcer to
form , the gumma, like most of the manifesta-
tions of interstitial kcratitis, undergoes slow
involution in most instances
The paiticipation of the uveal tract of the
eye in mterstiti.il keiatitis is one of the marked
features of the disease It is dithcult to form
an estimate of the depths in tho cornea of the
changes even with a highly magnifying lens
especially as in tho period of evolution the
irtitative symptoms present caieful examina-
tion, but the deposits in Descemct's membrane
are geneially »ell-maiked dots of varying size,
sometimes densely crowded and \ery fine, at
othei times large, like sjM>ts ot giease , these
aie eithei scatteied generally ovei the back of
the cornea, 01 chiefly collected at the lowei
put Occasional ly the appearances suggest an
almost umvcisal change in the endothclium in
certain areas of the lowei part ot the (oinca, as
it theie were an irregular deposit of amorphous
uetac eous gianules on it
Intis is shown by hyperjemia of the iris,
postenoi synechi.e, and exudations into the
pupillary aie.i , the failure, of the pupil to dilate
under ati opine is sometimes maiked, e\en when
on reio\ery theie can bo found little 01 no sign
ot past intis the failuic of dilation probably
arises from the absence of absorption ot the
ati opine thiough the inflamed cornea After
iccoveiy it is often possible to make out leccut
cvtcnsuc pcnphcial choroiditis, eithei in the
dftei ted eye 01 its fellow The shaie taken by
the u\eal tract ^anes from a degiec in which it
can scaicelv be venhed to almost pine indo-
f}chtis, with slight involvement of the cornea
only
A rule, with scaiceh any exception, is that
the disease oecuis in both eyes, the mteival
between the two, ho .v ever, may be as much as
fiom thi eo to four yeais , recununces may take
place, but attei a typical well-developed attack
they are lare Among young clnldien it is not
uncommon to sue slight attacks ot mteistitial
keiatitis 01 hybnd mteistitial and phljctenulai
attacks iccuiiing several times, followed at a
somewhat later poiiod in hto by a \v ell-developed
attack of mteistitial keratitis, after which theie
is no moie trouble
It is well to warn the patient's fi lends, as soon
as the natuie of the affection is lecogmscd, of
its piobable duration, of the almost certain
involvement soonei 01 later of the other eye,
and also ot the ultimate probable recovery of
veiy useful vision Nothing is so encouraging
to the patient as the assurance of lecovery
during the long weeks of suffeimg
G'ausfb of Intel *titmf Kemtitn> — ft is moie
common in females than in males , the age of
greatest prevalence is fiom about seven to
eighteen, but these limits aie not \eiy stiict
I have seen a few cases in quite young children
under the age of two, and it is not uncommonly
seen up to twenty-five, and sometimes up to
thnty jcais
The most frequent cause of interstitial kerat-
itis is hereditary syphilis, v\hich in most of the
cases may be recognised by its stigmata without
haMiig to question the patents directly But
CORNEA
evidence of repeated miscarriages, or of prema-
ture births, or of great moitahty among the
children in eaily life, may be easily obtained, as
al&o the testimony as to infantile skin eruptions
01 snuffles '<
The signs by which heieditaiy syphilis may ,
bo recognised are by the shape of the cranium,
the physiognomy, the teeth, and the choroid i
The fiontal eminences ,uo j)iominent and j
rounded , the (.entr.il part of the face is de-
pressed owing to the sunken budge of the nose
and to the flattening of the front of the supei lor
maxillary bones The mouth itself shows lineal
cicatrices radiating outwards espec lally fiom the
angles, and ficquently depressed cicatrices aie
seen in the skin of the neighbourhood Shotty
lymphatic glands may be felt in the nee k, and
the throat shows signs of old ulcer, it ion An
examination of the choioid of the othci eje by
the ophthalmoscope will often leveal the scars
of old disseminated choroiditis
The appearance of the teeth is one of the
most chaiacteristic signs of mheiited syphilis
in the milk teeth theie is nothing charactenstic,
but the mcisois veiy often become canons In
the peimanent teeth .ittention should be diiectcd
to tlie upper cential nuisors, .ilthough the otheis
may also show signs In the upper cential
mcisois two main tvpcs aie met with, those in
which the cutting-edge is n.iuowed mid has .1
cential notch in it, and those m which the notdi
is not piesent, but the c uttmg-edge is ninth
ii.ii lower and thnmei than the ciown of the
tooth, the sciew-dnvei type The teeth aie
also undeiM/ed and sepaiated fiom one .inothei
by spaces
Othei manifestations of inheiited syphilis are
deafness fiom internal eat disease, periosteal
nodes, 01 effusions into the knee-joints
Interstitial kciatitis also occurs laiely in
acquned Nvphilis , its couise is much the same
as in the heieditaiy disease
Cases occur occasionally in w hu h the most
searching examination of the patient fails to
reveal any of the signs of heieditaiy syphilis,
and in which no evidence in favour ot it can be
obtained fiom the family histoiy Siu h patients
aie frequently in Kid health and are rapidly
losing flesh , it is not possible to demonstiate
the presence of tubercle in such cases, but the
probability of it is gicat, especially whcic theie
aio nodular growths springing fiom the angle of
the an tenor chambei, as sometimes occurs in
such eases Microscopically nodules very sug-
gestive of tubercle have been found m the angle
of the antenoi chamber, and the tubercle bacillus
has been identified m the cornea in one case by
Zimmermann
The opportunities foi examining by the micio-
scopc an eye in the acute stage of interstitial
keratitis have been very rare Such an examina-
tion shows a cellular mfiltiation of the posterior
half of the cornea increasing in density as the
posterioi elastic lamina is approached , at this
point the cellular intiltiation w so gieat that
the conica appeals to consist entirel) of lound-
celled exudation , its proper structme is hidden
Descemet's membiane is thrown into folds, and
there aie deposits of round cells upon the endo
tlieliuxn Newly-iormed blood-vessels are present
mthedeepci labels of the/ cornea Theantenoi
lajers appear noimal The lound-cclled mtiltia-
tion also invades the ligamcntuin pectinatum,
the ins, and ciliary bod)
Ti aliment— Much may be done to alleviate
pain and distiess m interstitial keiatitis Pio-
tection from light should be setuied by dark
goggles, or a shade made to cover both eyes
Heat, b} means of hot compresses 01 fomenta-
tions, is occasionally \eiy useful in icducmg the
discomfort of the patient Locally we should
carefully avoid the use. of am kind of iiutant
as long as the disease is advancing Ati opine,
t gi to the oiiiue ot vaseline, should be used to
pi event 01 limit the effects oi iritis, and its use
should be maintained until the height of the
disease is well past \\henthesjmptomsha\e
begun to abate, iiutant oi stimulant lemedies
may be begun, the chief among which aie the
>ellovv oxide of merciuy ointment, which should
be begun cautiously m a stiength of four grams
to the finnre Calomel may be flu ked into the
eye, oi hot steam applied, 01 wine of opium
diopped in It theie is any icturn of nntatiou
then UM? must be discontinued The coniea
may be furthei stimulated to clcai by massage
combined with the use of the jellovv ointment
This tieatment mav be continued ioi months
01 jears
AM a lule most cases do not require bandaging,
but if there is a probability of the coinea jieldmg
to picssme it must be suppoitcd
lu the rmi \titut tonnl treat mr nt mercuiy should
be used, the mctluxl by mum turn being perhaps
the most satisfactoiy foi pi olonged use, 01 mer-
cur> with chalk may be given, caie being taken
that the patient be not sahv atcd As the patients
aie often an.imnc and miu h depiesscd, this treat-
ment should be combined with syiup of the
iodide of non and cod-hvei oil, at the same
time geneial hygienic measures, vvaim clothing,
good fo-)d, and tiesh an should be secured In
any case the results ot treatment ai e not hi ilhant ,
the disease appeals to run its course unchanged
and to imade the second eje while the patient
is still uiidoi treatment foi the hist Howevei,
theie is something to be done by constitutional
tieatment, fiom obsei \ ation of case's at the
Victoria Hospital foi Children during a series
of years, I found that the cases which \veie
tieatcd liy meic-ury lan «i shoitei couise and
had less tendency to recur than those not so
tieated, and also that the complications, such as.
exticmc deafness, were more frequent in those
not under mercurial treatment
LOCALMD IMJR^UIHL Kauri ris nt
240
CORNEA
(Koratitis piofunda) — A grey opacity appears in
the deeper layers ot the cornea ne«u its centre ,
it consists of maculfe 01 stiiuc, sometimes the
centie of the opaque area is compaiativcly cleai,
the opacity foi tunica not very dense ring lound
tlie ccntie, the stna» .ire geneially been in the
earlier stages, and \vhen the opacity is fully
developed they disappear Theic is frequently
deposit on the back of the coinca, and evidence
of iritis 01 iiido-cyclitis, and vessels may gio\\
into the coined iiom the pcnpheiy At its
height the condition of the eye much icse rubles
the mteistititil keiatitis of hcicditaiy syphilis
There IB gencially not a great amount of irrita-
tion, the attack lasts a month or six weeks,
and passes oil, leaving a certain amount of pei-
manent opacity The ]>atients are generally
beyond middle life, and onlj one eye is as a
rule attacked
The causes of the disease are obsciuc it has
been asciibed to cold, to rheumatism, to malaiia ,
many of its subjects suffer from defective tei-
mmal cnculation, cold hands <ind feet, dyspeptic
tioubles, and constipation The local ttuittttent
should be piotoetive glasses 01 a bandage, hot
fomentations and att opine, 4 gi to the ounce
of vaseline , the geueial treatment should be in
accordance \\ith the requncments ot etch case
tiutiAiFT* KiKAiiu^ — The appeal ance ot giey
lines in the coineal substance occ'ius m a vauety
of conditions, delicate giey lines are often seen
extending at right angles to a wound in the
corneal substance, \\hethcr the whole cornea has
been cut through 01 not, they are sometimes
present extending from the area of a deep ulcer ,
they occur in some cases of nitis and mdo-
c'hoioiditis, and aie not (infrequently the eailiest
f 01 111 taken by the opacity in mteistitial kei.it-
itis, they aie sometimes double-contoured, sug-
gesting a tube containing an opalescent fluid
They are said to be sometimes caused by a torn-
press which has been wotn foi a long time
Their most common appeal ance is aftei cataiact
cxti action, extending fiorn the \\ound at the
uppei pcnpheiy of the coinea dowmvaids into
the substance of the coinea, they aie moie
common \\heic the cornea has been much bruised
during the opciation, but a ccitam amount of
stnation is piescnt aftci nearly eveiy extraction
Striated kei.ititis is at most a tempoiaiy
phenomenon, it either disappeais entnely aftei
a short time, 01 gives \\.\y to some moie pei-
manent general haziness The explanation of
the occurrence of the lines is not simple , they
piobably have moie than one cause, there is
no stiiutme in the noimal coinea uhich coire-
sponds with them, but ccitam tubes can be
made to appear in the cornea by injecting be-
tween its lamella) mercury or air under pressure,
Bo \v man's tulxjs Some of the opaque lines aie
to be explained by the natural formation of
Bowman's tubes, by the pie&sure of fluids m
mflammatoiy conditions of the paits adjacent
to the cornea They have been foimcd experi-
mentally by making sections of the coinea m
labbits, and have been then found to be caused
by wrinkling of Desccmet's membrane , the kind
\vhich lollows cataiact extraction may have this
cause
Leprosy sometimes attacks the coinea, nodules
form generally at the margin of the cornea, asso-
ted with iritis, they generally break down,
leading to loss of the eye, the coinca is also
sometimes amcsthctie.
8<.Lf,R(MNi] KFiuriTi* — A i elapsing, pci-
sisteut, subacute inflammation oi the ciliaiy
legion imolvmg the adjacent part of the cornea,
and sometimes attended by iritis The lecur-
i entes generally occui in iiesh places, and the
general eftei t oi each attack is to loax e conical
01 ti singular areas of opacity at the margin of
the coinea xuth the base dnccted out \vaids,
these aioas aie sometimes veiy dense and blue-
tt bite in colour, and appioximate in appc, nance
to the sdeiotu
The cause is unknown The local tieatmcnt
should be rest, fomentations, and at i opine
C \n uinw Fint UP IHF COR\FA (Trans\eise
Calcareous Hand) — This is a ionu oi degenera-
tion \vhuh otuns in the supoihtial layeis of the
lointvi, in the sha]>c of a broad band oi o\al
patch ot duty giey coloui l>mg in the pait of
the coinea that is commonly exposed It lies
just beneath the epithelium, and consists mainly
of fine caleaioous gianules muted with hyaline
substance Its development is ve.iy slow , it
staits on each side of the cornea, and giadually
piogi esses towards the centie
It on m ft mostly in eyes that ha\e been lost
horn old indo-tytlitis, but is occasionally met
\uth in old people \\hose eyes aie otherwise
healthy
Tt«(fitttHt — If the eye is othei \viso good the
film maybe lemoved by sci aping and aiteiwaids
ti eating the coinea as if it had been mjuied
donyemtal OpMrtieb ot the Cwnea — In one
vanety of congenital opacity the coinca appears
to have the stiiutme ot scleiotic, the opaque
scleia seeming to extend for a certain distance
into the coinea, and only giadually thinning
into clear coinea Such eyes .ire often microph-
thalmic , the condition may be seen in moie
than one member of the iannly
In other eases a fine ring of opacity is seen
]ust inside the coineal margin, it has the same
appearance and situation as the areas senilis
(amis juvenihs)
Othei opacities are due to fa-tal inflammation,
such as interstitial opacities of vaiious kinds
In congenital hydrophthalmos the A\ hole cornea
is sometimes faintly milky
The at cm tenth* is a non- mflammatoiy de-
generation of the cornea, appealing as a grey
line at the upper and lower parts, and some-
times meeting at the outer and inner, it is
densest above and below, and is separated from
CORNEA
241
the sclera by a thin baud of tianspaieut cornea
The grey line IB due to a hyaline change in the
tissues of the cornea, and has no significance
Jttood-staminy of the cotnett is found when the
anterior chamtor has l>een filled \\ith blood for
a long time The coinea appears to he of a
red-brown colour, «iud is quite opaque , the ab-
sorption goes on very slowly from the peiiphcry
The staining ib due to deposit in the cornea of
blood crystals which have foirued aftci diffusion
of the blood colommg matter thiough Desccmet's
membrane
KetaMis Punctfita — This teim has already
been used, it is commonly applied to the do-
posits on the back of the cornea that ate met
with m inflammations of the ciliary ItKxly A
number of hue dots is seen on the back of tho
coiuea, sometimes evenly scatteied, but more
often found on a triangulai atea at the lo\\ei
pait of the coinea wheie thej aie formed by
deposition The dots consist ot shicds of tibim
and leucocytes cast otf ftom the ciliary bcxly and
deposited on the conical endothclmm Where
they are not soon removed by absorption they
pioduce destiuctive changes in the cndothelimn
Some oi these dots aie of laige size, and have
the appearance of spots of pease on the bock of
the coiuea It is possible that these deposits
may mcicase in si/c , when examined in the
fiesh state they have been found to contain
colonies of bactena (Snellen)
Contat! Cot n en The cential pait of the
coinea begins to bulge veiy gi.idually without
inflammatniy symptoms, fin miiiir a blunt cone,
in the more advanced cases the cnmcity is icadily
seen by looking at the piofile of the coinea
The disease makes itself felt by a distui bailee of
vision, objects can only be seen cleaily when
held close to the eye, yet the sight is scaicely
improved by concave glasses The shghtei
degiees may be lecogmsed by the ophthalmo-
scope by a shadow seen on the backgiound oi
the eye, ciesceutic 01 cnculai in shape, and
shifting with the movements of the muioi , the
condition mav also be iccogmsed bv examining
the comeal reflex with a Placido's disc, and com-
paring it with that f 10111 a noimal cornea
The disease may come to an end spontane-
ously, or in the woist cases a nebula may be
formed at the apex of the cone which is lather
below the centre of the cornea , perforation
never occurs
The affection is a laic one , it attacks lioth
eyes in young adults, especially women It is
atrophie in nature, and is due either to some
developmental peculianty in the corneal tissue,
or to defective nutrition in the part farthest
ic moved from the blood-vessels
Treatment — In the eaily stages some im-
provement may be eiJ'ected by prescribing con-
cave glasses with cylinders, the propci stiength
of which may be found out by the shadow test ,
these may be used either alone or combined with
an opaque screen having a small hole or narrow
slit cut in it Vision has been improved in
many cases by hyperbolic glasses as suggested
by Rechlmann
Of other methods of treatment eserine or
pilocarpine used continuously has been said to
reduce the comcity, but in most cases it is of
no use '
Operative measures, with the object of flatten-
ing the cone by forming a resistant cicatnx at
or neai it, are to be recommended where the
impairment of vision is very great
The apex of the cone may IMJ removed by
shaving it oft with a Oracle's knife without
opening the antenor chanibci, and aftei two
davs touching the raw surface with mitigated
nitrate of silver stick An elliptical flap may
be removed from the apex of the cone, and the
rumen aftei wards sutuied , a small disc of the
outer layers of the < one may l>e separated by a
Bowman's trephine, and the sin face allowed to
heal and contract Multiple puuctmcs may be
made into the apex of the cone with a fane
needle, and repeated after some weeks, or the
galvano-cauteiy may be used at a vcrj dull heat
to burn the sin face* lasers ot the coinea , if per-
iotatiou take place dining burning no haim will
lesult to the deeper parts if caie be used, as
the cautery is at once chilled by the escaping
aqueous This last method has the advantage
of being free from the risk of infection
IfyihojJtthnlmov (Buphthalmus) — The cornea
undeigoes geneial ami piogiossive enlaigement,
and sometimes becomes hazy in this affection.
The enlargement is pait of a general enlarge-
ment of the globe, and may be looked upon as
congenital en infantile glaucoma
Turnout* of the (Jotnea — Tumouis of tho
cornea aie larc M \xomata, hhromata, sarco-
mata have been descril>ed as well as epitheho-
mata starting from the limbus, and cysts following
inj unes, fonned by the inclusion of cells from
other parts in the comeal substance
IMIRIRS — fotevfn Kodiet* in the Coinea —
Foieign bodies, hagmeuts ot steel 01 11011, small
pieces of stone oi paitit les of ash from locomotive
engines, imbedded m the cornea, are very com-
mon accidents, and give use to vaiying amounts
ot [win and instability
They sometimes lemamior long penods with-
out ex( ituit* distui bance, as among tfiose engaged
in metal gtuiding, in whom the cornea may
often be seen studded with minute fragments of
stone which have been theie tin indefinite time
Si .iles ot seeds or the wing-cases of small insects
may iwlheie to the cornea by their concave
sin faces
Paiticlcs of steel 01 nun become partly oxi-
dised, and the ioieign bod\ may be otten seen
surrounded by a hi own ring, which consists of
sodden epithelium impiegnated with o\ide of
iron This nng may lemain behind after re-
moval of the paiticle, and continue to keep the
16
242
CORNEA
eye irritable. If not removed, foreign bodies
are generally cast off by exfoliation of the part
in which they are lying, dining the whole of
this time the eye is liable to infection at the
seat of the injury, especially where the lachrymal
sap is not healthy.
For their removal the eye should l>o thoroughly
cocainised, two drops of a 2 }>ei cent solution of
cocaine should be put into the eye throe times
at intervals of a minute , the patient should be
seated facing a light, the bin goon standing be-
hind him The lids being held ojien by the left
index and middle tnigets, the foieign body may
be removed, at hist by the edge of a piece of
clean blotting-paper, 01 if it is imbedded by a
spud or needle The ring of oxide lound the
foreign body should also be removed If the
anteiior chamber be penetrated other measures
must bo taken to pi event the object from being
pushed into the chamber, or the parts beneath
from being injured If of iron 01 steel, the .at-
tempt should be made to lemove it with a strong
magnet, this is often unsuccessful owing to
complete oxidation of the metal
Ksorme should then be used, one or two drops
of a solution ot 2 gr to the ounce, to conti.ut
the pupil and protect the parts beneath horn
injury A keratomo 01 broad needle bhould bo
passed into the anterioi c hambei and held against
the back of the cornea behind the {X'rfoiated
spot by an assistant This will prevent the
foreign body being thiiiht into the chambci by
the attempts at removal from the front of the
cornea which must mm be continued
After removal of any foreign body in which
the conical surface has been biokon, acompiess
should be kept on till the wound is healed, and
atropme should bo iibed as for the treatment of
a cornea! ulcci , but where the anteiior chamboi
has l>een opened the ati opine should not be u&cd
until it has bee ome closed
Sometimes the track of a perforation made by
a particle of metal can be been in the cornea
without any trace of the object itbelf The ins
should be examined caiefully, the pupil should
then 1x3 dilated, the leiib minutely inspected, and
the fundiis sybtcmatu .illy examined by the oph-
thalmoscope Finally, in cases ot doubt or
difficulty the X-rays may be used to determine
the presence or absence of a foieign body
Wounds of the coinca made by blunt or jagged
instruments are often irregular, and their edges
will not come into apportion If the ins is pio-
truding, the exposed pait should be drawn
slightly forward free from the edges and cut oft ,
the edges ot the cut iris should then be tucked
back It is not advisable to attempt to return
to the interior of the eye a piece of ins which
has been btuibcd in the wound and exposed to
septic contamination A veiy useful measure
in closing gaping wounds of the coniea is to
dissect up a flap from the adjoining conjunc-
tiva and place it over the wound in the cornea
after thoroughly washing the parts with an
imgator
jRumv — After scalds by hot water, or bums
by acids or alkalies, the cornea looks steamy and
dull The extent of the injury depends to some
degree upon the nature ot the agent effecting it,
alkalies, lime, or sulphuric add produce serious
and permanent damage, whereas even strong
nitric acid or blistering fluid may effect only
temporary damage In the worst cases the
cornea appears dry and vv hite, and is completely
anesthetic, this condition is likely to end in
complete necrosis Lime burns aie among the
most common injuries, but fortunately the lime
is nearly always pirtially slaked the full effect
of lime 01 caustic alkalies is produced M?iy
slowly, and only as recovery takes place can the
amount of cicatrisation be appreciated In every
injury of this kind the prognosis should at hist
be strictly guarded even where the change ap-
peal s to be blight only, owing to cicatncial
changes the conjunctiva may be diavvn more 01
loss ovei the coniea, 01 adhesions may form
between the lid and the coinca
Treatment — All tiace ot the caustic agent
should bo removed, treatment should be by
rest, a compress and ati opine, a few drops ot a
solution of 2 gi to the oum e once a day The
contractile cicatrisation should be pi evented as
fai as possible by putting in pine castor oil
thiee times a day, and ome a day allowing fice
movement of the eye in all dnections, carefully
separating the lid from the eve
Injuries ot the Cornea — Superficial abrasions
aie extremely painful, and cause much watenng
hypciomiia and intolerant e of light owing to the
friction ot the lid against the1 denuded surface
These injuries aie frequently caused by branches
or leaves of tiees, 01 by the fingei-nail The
loss of sin face is generally confined to the epi-
thelial layei, and is not eahity seen unless we
examine the conical reflex
Treatment - -The film application of a com-
piess and ati opine, in the ioim of an ointment
(4 gr to the ounce), cocaine gives tempoiary
relief, but the prolonged use ot it is likely to
produce boftening of the epithelium As sleep
is often imposbible it may be .idv isablc to give a
hypnotic Rest and immobility of the eye foi a
few houis are enough to secure regeneration of
the epithelium
Relapses of abrasion aie sometimes seen with-
out any fresh injury (see "Relapsing Billions
Keratitis ")
Cornet Player's Emphysema.
Kee LUNGS, EMPHYSEMA (Inducmy Causes)
Corn-flOUr. >SV<? D«r (VegetaWe Foods,
Cereals), INVALID FEEDING (Diet during Con-
valescence, Corn-flout)
Cor nil. — Cornu, literally a horn, means a
horn-shaped process or projection, e g of a cavity,
COKNU
243
such OH that of the lateral ventricle of the brain ,
thus, there are the anterior und posterior grey
cornua of the spinal cord, the coniua of the
thyroid cartilage and body and of the thynius
gland, the cornua of the lateral ventricles of
the brain, the cornua of the hyoid bone, and
the cornua of the uterus
Cornutiru
See ALKALOIDS
-An active alkaloid of ergot
Corona Radlata. See PHYSIOLOGY,
NER\OUH SYSTEM (Cerebium, Corona Radi ata) }
GENERATION, FEMATA ORUAYHO* (Ownet, Mmo-
scopic Appearance*)
Coronal Suture. See LAHOUH, PHYSIO-
LOGY (Tlnid Factor, Pawnyer, Ftftol /lend)
Coronary Arteries. See
PmsioLO(»Y ot (Coionary Circulation) , HEART,
MYOCARDIUM, AiruTiovs OF (Chronic Inlet -
stitial MyocnnhtiK, Atteiw srfrrewi of Coranmy
Aifenei), PmsioLOM, CIRCULATION (Flow of
Hlowt though the II fait)
Coroner. *SW MEDICINK, FORENSIC (Cet
tfftnition of Death, Piotedme tn England and
Wale")
Corpora. See CORPUS
Corpore Conduplicato. -Bnth
" \\ith Ixxly doubled up," occulting A cry inioly
in cases ot tians^ eisc piesentation See LABOUR,
DIAGNOSIS AND MECHAXISM (Tianweiw Lies,
Spontaneous Dehvety)
Corpulence. See OHESITY
CorpUS. — A body (plmal coipoia) , a fre-
quently employed tuim in aiLitomy, ey corpoia
Aiantn, corpus callosuni, corpoia eavernosa,
corpus denticulatum, ccnpoia lutea, corpora
oiy/oidea (rice-like Ixxhes in joints), corpoia
quadiigeiuina, coipus striatum, corpus vitreuni,
etc
CorpUSCle. -A cell, a cell-like bod\, or
an .iggregation of cells, e q led and white bl<xxl
coipubcles (we ANMJMIA , BLOOD, Cellular Con-
stituent*) , colostrum coipusc les (tee COLON i RUM ,
MILK), coipuHcles of (Jrandry, Kiause, and
Viiter , Malpighian corpuscles , Lavcian's cor-
puscles (*>ee MALARIA) , Pacnuan corpuscles, etc
Corrlffan'S Button. See CAUTERY
(Actual)
Corriffan'8 Pulse. See HEART, M\o-
CARDIUM AND ENDOCARDIUM (1'kyuca? Sign* in
Different Form* of Heart J)wea*e, J*ul*e in Aortic
Incompetence)
Corrlffens.— The comgens is the ingredi-
ent in a prescription \\hith corrects the action
of the basis or pnucipal ingredient See PBE-
Corroslve Sublimate. See MER-
CURY (llydiarqyn Pet cMoridum) , CHOIEHA,
EPIDEMIC (Dtaunou*) , TOXICOLOGY (Coi-totm
Poisoning, Mercurial Pononiny)
Corsets. See PRE(iVANC\, MANAGEMENT,
PELVIH, P^RINJUM AVD PBIAIC FLOOR (Prolapsus
Uteii, Causes), I'UERPEHIUM, ^ATHOLOGY (Sore
fi'ijyples, Pieditpostmj Canter), SPINE, SURGICAL
AFFECTIONS OP (tipinal Carte*, Treatment by
Platfei Jadets)
Cortex. — The outer part of the hiibstancc
of the biain, the kidney, the ovaiy, the supia-
n>nal capbiile, etc (tee BRAIN , GENERATION,
FEMALE OIK.ANS of, et( ) , also the bark or rind,
erf cortei vinihvci (buinbucus bark)
Cortl, Or^an Of. Se,- PII\MOLOGY,
THE SKNSES (1/ttumt/, Intonal Ear)
CorybantfiSm.— u A stitc of excitement
(piobablv hysterical) AC coinpanied by choreic
movements, fantastic > iMial hallucinations, and
sleeplessness " (Hack Take), the name takes its
origin from the corybantes or pnests of Cvbele,
vho beha\ed in a delnious fashion at their
cclcbiatiom*
Coryza. — Nas.il cutanh Kef NOSE,
ACUPE JNILAMMAIION (Aiute Jthinttn) , NOSE,
(him IMP INF LAM MA i ION (Corya in C/iiMten) ,
NOSE, NASVL NEUROSES (Coiyza Van-motorta
Peiiodua, (1ntya (Kdenwitowt) , NOSE, ArcEhhORY
SiNLMis, INFLAMMAIIOV (in Acute Coiy~a) ,
Antnpm, LNFAMIIE (Dmi/nom, Suphddic
Cottj-a). (/oCAiNh (^se1?, Acute Coryza) ,
MLASLbb (Couiw) , ME\I\(,nis, ElMDtMIC
CEKEURO-JSPINAL (Iteipuatoiy Symptoms)
COSClnlum.— False calumba or the dried
stem ot CovtniuM ten*«tratum , oftin.il in the
Indian and Colonial Addendum to the Butish
PhannacopuMa , it has the same action and uscb
as ordinary calumba root (q v ), and there are
three jnepai.it ions ot it, vi/ the Infusum
Cttuinn (dose, J to 1 fl oz ), the LK/UOI Coscmii
Concenti at u* (dose, J to 1 fl dr ), and the
Titutnia Commit (dose, J to 1 fl dr )
CosmetlCS. — Operations 01 medi(al a|>
pluatioiih, etc, for the purpose of restoring
natmal beauty , such a plastic pioceduie us the
repaii of a hare-lip is a cosmetic opeiation, and
taiious po\\ders and ointments (some of which
contain lead) are used foi "impiowng" the
complex ion See DKRMAIUIS TRAUMATICA ET
VENENAIA (Causal Ayents, Chemical Confounds) ,
TRADES, DANGEROUS (Lead-Powmtug)
COSta- Or CostO-.— Costar or rosto- m
compound Avords means relating to a rib, thus
costalgia is intercostal neuialgia, co&to-coracoui
is related to a rib and to the coracoid process of
the scapula, etc
244
COSTER'S PASTE
Paste.— A paste containing
120 grams of iodine dissolved m one fluid ounce
of light oil of wood tar, it IB sometimes em-
ployed as a parasiticide in cases of ringworm
COSt I VOneSS.— -Constipation, 01, more
correctly, a less degree of intestinal inefficiency
than is met with in constipation See CON-
STIPATION.
Cotarnlna. — An alkaloid, C^NO,,
obtained from narcotma (C^H^NOy) by oxida-
tion , its hjdiochloudc is ttypticni ((/ v ) See
ALKAIOIDS, SnpnciN
CotO Cortex. — Coto Uuk is a non-official
ding, used sometimes to iheek diaiihoja , there
is a Ttuctwa Coto, of which the dose is 10 m
every two horns (with mucilage), the actne
principle is cotoin (CJ2H18O,,), a glucoside, and
has been used foi the "same purpose
Cotterlll's Operation. See
SURGERY OP ( Wayne i 'i Opt t ation, J/ocfc/h atton of )
Cotton Root Bark.— <7o<.<///"< Radici*
Cortex or cotton root bark is got from the
Gossypiittn hctbateum, and is othcial m the Indian
and Colonial Addendum to the Jbitish Thaima-
oopcma , its ptcpaiations uio the Detoctnnt
Gossypu Rathci* Cnrticis (dose, £ to 2 fl o/ )
and the Ejrtiactnm Gotsypu Railicis Cotticis
Lu/uulum (close, J to 1 11 di ) , it has the action
and uses of ergot"
Cotton - WOOL— Cotton, Gowypnun, or
cotton-wool is the hnu of the seeds of various
species of Gostypium , if the oil have been ic-
moved it is known its "absorlwnt cotton-wool" ,
if not, as " non - absorbent wool" See also
COLLODIUM , I'^ROXYLINUM , TRADES, DANGEROUS
(Textile Ttade*, Cotton Wm/iert) Cotton may
1x3 impregnated with vaiious medicinal sub-
stances (antiseptic, hiemostatic), and it is then
known as lodofoim cotton, salicylic cotton,
iodised cotton, sublimated cotton, humiostatic
cotton (containing feme rhlondc and alum),
and Nankeen cotton (containing picric acid)
CotUffnO'S Disease. See SCIATICA
Cotyledon. S*e FUJU.S AND OMJM, DE-
\ EI-OPMENT OF (Placenta at Tet m)
CotylOld. — Literally, cotyloid (from
Korv\i), a cup, and eiSos, losemblance) means
cup-like , in anatomy it signifies i elating to the
acotabuhnu See HiP-Joivr, DISEASES
Couoh QraSS. See AUROPYRUM.
Couching. — An operation employed in
cases of cataiact for bt caking down the opaque
crystalline lens (ey by means of a couthmg-
noedlo) in oidei to produce reclmation 01
absoiption See CATARACT (Tttatment, Opeta
tive,
Cough. See AORTA, THORACIC, ANEUBYSM
(Symptoms), BRONCHI, BRONCHIAL GI^ANDS
(Pressure Effect*, Dun/now*), BRONCHI, BRON-
CHITIS (Symptoms) y BRONCHI, BRONCHIECTASIS
(Symptoms) , CHILDREN, CLINICAL EXAMINATION
OF (ftespimtmy System, The Couyh) , GOUT
(He'tpitatoty Syitem) , HYPNOTISM, HYSTERIA
(Dtiotdets of Respiratory Orgam, C(tuyh) ,
IJARYNX, BIS.NIGN GROWTHS OF (Symptoms) ,
LI\ER, DISEASES or (J/epatoptosts, Symj>tams\ ,
LI\ER, PERIHEPATITIS (Signs and Symptoms),
LI\ER, CONGESTION , LUNH, TUHEUCULOSIS OF
(Luntj Symptoms) , LUNC.S, EMPHYSEMA OP
(Causes) , MEDIASTINUM (Chiomc Metliatiinitis,
Synyrtoni*) , PH^NIOLUGY, RESPIR \TION (Sjtecial
flttpnatfny Movement*), SPASM (Spasmodic
Cough 01 Cynobea Hetotis) , SIOMACH AND DUO-
DENUM, DisEAShs OF (Genual Sytnptom<itoloi/y) ;
THYROID GLAND, MEDIC \L (Kj ophthalmic Goitre,
Symjtton^ Respiratory System) — Cough is an
nnpoi tant symptom m many diseases, and may
constitute the chief compLunt of the patient,
while in other diseases the presence and char-
acter of a cough hardly noticed by the patient
limy give impoitant aid in diagnosis
The Art of Cow/htnt/ — Coughing is mainly an
expnatoiy act in which an is expelled explosively
through the mouth An is diawn into the chest
and shut m by the closuie ol the glottis The
intr.it hoi acic tension is mcre.ised The gates of
the Luynx aie then opened, and the iniptisoned
•in escapes explosively The gates ot the laiynx
are the tine and the false vocal coids it is by
the apposition of the false \ocal eon Is that the
mtiathor.u'ic tension can bo me leased to a
sufficient degiee to permit of an explosive cough
In animals, such as the sheep, in which the
ialbC cords and the ventncles ot Moigagni arc
undeveloped, there is no proper explosion on
coughing
Cough may be \oluntary, but is usually le-
fle\ When the irritation is not too stioug, the
impulse to cough can be Aoluntarily les trained
The impulse to cough commonly results from
irritation ot some of the biaiuhes ot the vagus,
and may piocecd fiom —
1 The respnatory mucous membrane (naso-
pharynx, larynx, trachea, bionchi)
2 Aural imtation, as from foreign bodies m
the extenial meatns, or rarely from chronic otitis
3 The back of the tongue, through the lingual
branch of the supciior laryngeal nerve
4 Gastnc irritation— the "stomach cough"
which occurs in association with chiomc
dyspepsia both m childicn and adults
5 Irritation of branches of the vagus by
enlarged bronchial glands, or by enlarged
glands, turn 0111 s, or abscesses in the mediastinum.
C The skin, especially of the throat and
chest.
Apart from local irritation, cough may be
purely " nervous "
THE CLINICAL VARIETIES op COUUH — Diseases
COUGH
245
of the Larynr. — In simple and m membranous
laryngitis the cough is commonly hoarse, bark-
ing, and imperfect, or, as is usually said, cioupy
In nlceratum or thickening of the mucous mem-
brane of the laiynx the cough may be husky
and impcifect, or may be loud and clanging
When a malignant turnout 01 <ui aneurysm
presses upon the trachea, or involves the ie-
current laryngeal neive, the cough is commonly
loud, resonant, and biassy, and has been com-
pared to the cry of a gander
In paralysis of both vocal cords the patient
is unable to cough, in abdwtoi paralysis,
whether unilateral or bilateral, the cough is
unaffected, in adductor paialysis there is per-
fect cough combined with aphonia
Diseases of the Luiujs — In /Bronchitis the
cough is at first short and diy, and may be
painful , as secretion increases it becomes moist,
and may be paroxysmal Severe paroxysmal
cough may be present in JU»oid 2>hthiw, and,
more < haracteristically, in fiionihiettaua In
phthntb cough is one of the early symptoms
At fust it is dry and hacking , later it becomes
loose, and is attended with mmo-purulent 01
purulent expectoration When cavities develop
the cough may become paroxysmal, and is of ten
most se\eie m the nioimug Occasionally
advanced, and even advancing, phthisis may be
present with entiie 01 almost entire absence of
cough This occiu s espec iall\ in lunatic patients
In jmeHinoHHi the cough is frequent, short, dry,
resti amed, and associated with severe pain in
the side In acute jj/o/my cough is usually,
but not always, present It is seldom so dis-
tressing as m acute pneumonia
The paroxysmal tough of ^wtasi/s is xery
characteristic A series of coughs follow each
other so rapidly that no inspiration can occur
The patient becomes cyanosed, the \ emu of the
forehead and scalp become distended, the eyes
become piomment, and the tongue is often pro-
truded Bleeding from the nose ma} occui
At List a sudden inspnation takes place with a
loud whoop Tins may be followed immediately
by a second or by seveial seiies of coughs and
whoops befoie the paroxysm is oxer At the
end of the paroxysm a quantity of mucus is
generally expelled with some violence, and in
young children vomiting is usual Duniig the
paioxysm the child seizes hold of its muse or of
some piece of furniture for support, in order
to give pui chase to the accessoiy muscles of
respiration In pertussis the cough is apt to l>e
most troublesome at night
Enlaiged glands at the loot of the lung may
give rise to very severe and persistent coughing,
sometimes paioxysmal in chaiacter, either by
pressure on a bi ouch us 01 by irritation of
branches of the vagus When symptoms of
pressure on a bronchus are absent it is often
difficult to make out the cause of the cough
Eustace Smith has called attention to a physical
sign often met with in these cases If the
child is marie to throw the head as far back as
possible, a bruit is heard on auscultation over
the manubrium sterm which disappear \vhen
the head is brought forward again He attri-
butes the murmui to prcssuie on the left
innominate vein
It must never IHJ forgotteivthat the irritation
of the pulmonary branches of the vagus giving
use to cough may itself bo secondaiy to some
other condition , for example, measles, typhoid
fevei, or some other infectious disease, to
chionic heait disease or to Unght's disease
Diveavr* of the Heart — Pericarditis is some-
times attended by a hard painful cough
Valvulai disease, and especially mitral stenosis
and mitral incompetence during the stage of
lulling compensation, aie accompanied by cough,
often with watery or blood-stained expectoration
AneuryMii of the aorta may give use to very
distiessing cough, either by dnect pressure on
trachea or bronchus, or by nritation of the
recmrent laryngcul neive
Any condition in which the heatt's action is
feeble, and \\heic < onsequently the cnculation
through the lung is carried on nnpcifectly, may
give rise to a troublesome cough
Diwtvei, of the Abdominal Viwa — The
"stomach cough" associated with indigestion
has aheady been mentioned The existence of
a true " stomach cough " h.is been doubted, and
it may be admitted that such a diagnosis may
legitimately lie regaided with some scepticism
In many cases of the kind the cough appears to
be due to pharyngeal nritation associated with
the dyspepsia The imtation pioduccd by
ento/oa is said occasionally to give rise to cough
Cough may be piescnt in pathological condi-
tions of the ovaries and tubes, and piegiiancy is
also regaided an an occasional cause
Neutouii Comjh — The term "neivous cough "
may be applied to all forms of cough in which
no cause of lo<.il nritation can be discovered
Nervous cough may be a meie habit, more
annc>)inu; to the heaiei than to the subject
Its occuiience is oiten associated with emotion,
particulaily the emotion of speaking m public
Some foims of UCIAOUS cough have ahead) been
i of erred to
Hi/bteimif (omjh is compaiatixely common in
cases of hystena It may be very sc\ere and
peisistent, and grve use to serious appi ehensions
as to the condition of the lungs
The j*i imfmil myht aniyh occurs in children
The cough comes on in paroxysms about the
middle of the night, and may last for several
houis It is probably often due to nritation of
the vagus by enlarged lymph nodes
About the tune of }>uhnty a loud barking
cough, reclining at frequent intervals, is not
uncommon in boys of nomotic constitution
Diagnow — Some foims of cough, such as
the cough of pertussis or of aneurysm, are \cry
246
COUGH
characteristic, and many more are easily traced
to their origin. The difficulty in diagnosis is
greatest where no obvious disease of the pluuyux,
larynx, trachea, bronchi, or lungs can be made
out, nor of the heait 01 aoita Such cases
should not lie too quickly het down as neiums
Repeated examination should be made of all
possible sites of local nutation In childien the
ears and the naso-phaiynx should be cat chilly
examined, and the possibility of enlaigement oi
glands of the tx.ichco-hronchial gioup mubt be
borne in mind The family hihtoiy should also
be inquired into, especially with leferencc to
any tendency to tuberculosis 01 nemosis
Hysterical cough may be piesent in eithct
childien or adults In women the possibility
of pregnancy 01 of pehic disease being le-
sponsiblc must be considered In adults, and
especially in eldeily patients, any evidence of
feebleness of the circulation, biich ,is weakness
of the pulse 01 coldness of the evtiemities, is of
importance
2TirriCmrnr--The treatment of cough due to
diseases of the icspiratory oigans or of tho
heait and aoita will be found detailed undei
the appropriate he.idmgs Excluding tliese, the
throat will frequently be found to be the seat
of nntition, and pharyngitis, enlarged tonsils,
or elongated uvula will icqiinc local treatment
Gargles, sprays, pigments, pastilles, are all
useful in suitable rases The gieat benefit often
to be derived fiom constitutional treatment, sea-
bathing, and an outdooi life is not always
sufficiently recognised
Inhalations aie of value when the i filiation
proceeds horn the laiynx, and the use of the
bronchitis kettle and copious warm alkaline
dunks are most valuable adjuvants in all con-
ditions wheic the cough is aggravated by scanti-
ness or viscidity of the e\pcctoiation
"Eai " cough usually disap{>eais immediately
on the lemoval of the cause of the lo«al nnta-
tion, often a plug of w.ix 01 a foieign bcxly, such
as a bead, mscitcd m the eat by the patient
"Stomach" cough is to be tieatcd by a
suitable dietary, and the use of gastric sedatives
such as bismuth and hvdroc^amc acid
The barking cough of pubeity w best heated
by a plain but sufficient dietaij, active out-
dooi exuicise, early hours, and the use of
tonics Sn Andiew Cl.uk was in the habit of
oidermg the syiup of the biomide of iron, with
small doses of arsenic
The dangei attending the indistiimmatc and
injudicious use ot sedatives and narcotics
(especially opiates) in the tieatment of cough,
and the disastrous consequent es whuh ma}
lesult m voung children and elderly patients
espeuallv, aie piettv geneially lecognised
Novel theless, it must not be forgotten that
severe and piolon^ed coughing, coughing out of
all pioportion to the amount of the expcctoiation,
if unrestiamed, involves a great strain on tho
lung, and may result m serious mischief to the
lung tissue. Where a sedative is leqnircd small
doses of chloial oi of tho bromides are often
piefeiable to ophites Cluldien aie not infre-
quently kept awake by an initative cough which
can be at once leheved by a lew grams of
chloial
The biomides aie of value in all foims of
paioxysmal cough, and ammonium biomide has
long been a favouiitc remedy m peitussis Some
cases of peitussis aie gieatly rche\ ed by antipyim
in doses ol about 1 giain hn each yeai of the
child's ai»e
In eldeily patients a chiomc cough associated
with slight bionchial catarili oi congestion of
the bases, and which has tailed to 1 touch t by the
usual lemedios, will often disappcai undei a
couise of digitalis in small doses Strychnine
is also oi value in some oi these cases
Coulomb. — The quantity oi electucity
develojKMl by a cuiient of 1 am])cie , the amount
pioduced bv an eloctio-motive toice ot I volt
acting foi 1 second against 1 ohm of lesistance ,
the piactical unit of elect IK quantity, named
after Coulomb, a French ele<tntian
Counter Irritation.— The attempt to
dimmish some mtcinal moibid action, such as
inflammation of an oigau, hv/ «ippl)ing nritatioii
externally , " derivation b} nutation" See
CAUSTICS, CA
Counter Opening.— A second opening
made into an abscess cavity or othei accumu-
lation ot fluid usually .it a distance horn the
fust opening, in oidei moie easily and thoroughly
to di.un the cavitv.
Country Fever.-— A "continued thei-
mic ievei '' occiining m the Caiolmas, Mi]>posed
to be due to the piolongcd action oi high tem-
peiatiues, but often mistaken ioi malaria or
typhoid fever, sunstioke (7 v )
Coup-de-SOleil. #«• SUNSTROKE
"Courses." AVr Mi- NSIHUAI ION AMJ 11 s
DISOHDKKS ( Tct nimoloyy)
Court Evidence. A»Ve
(/W-//W) tent Jtepmt* and
CourvolSier'S Law. — Concoins the
state of the gall-bladder in common bile-duct
obstruction It is that, with some exceptions,
when distinction oi the common bile-duct is
due to calculus the gall-bladdei is not enlaiged ,
whereas m obstiuction due to othei causes,
notably malignant disease, enlaigement is tho
mlo Persistent jaundice, therefoie, with a
distended gall-bladdci, accoiding to this "law"
indicates usually malignant disease
— An apparatus, usually a
COUVEUSE
247
wooden or metal box, with appliances (hot
bottles, or cavity containing hot water) for
maintaining a constant temperature, used for
the rearing of delicate 01 piematuie infants , an
nicubatoi See PREMAIUKJJ, INFANIS
COWlS. See \ KVT1LATION AM» WARM1M!
(Va<unm ot A'ulmr/to/i tit/rfims, CW/s)
COW per It IS. — Inflammation of C'o\vj>ei's
glands (7 ?» )
Cowper's Glands. See I.HETHUI,
DishASJiS OF (Anatomy, Male fifth a)
CowpOX. Set VAC< INATIOV
COW-ShedS. — A cow-shed is any dany
in which milking cows aie kept, it shall he
sufficiently lighted and ventilated, «ind shall
provide a minimum spate of NOO cubic feet pel
cow , its dtains sli.ill be t Kipped, and it shall
IK? piouded \\ith watei-tap and hose foi thoiouuh
and fiequent < leansmg , the tiooi shall be ot an
impel \ ions mateiial (concrete) and piopoilv
sloped and diamed The roof and walls shall
bp lime-washed (say, twite a veai), and the
shed should not be neaiei a human habitation
than 100 feet See Mi IK (Induitmtt)
COW'S Milk. See MILK , IM \NT FEEDIM,
(AitifHtal) , INVALID FLLIHMS (Milk and ttt
]J)rtf?intt) , etc
COXalKla.-P.un m the hip, aKo hip-
joint disease tit? APPENDIX VERMIFORMIS,
APPF\I>I< ins (f)ia</nov) , HVMLRIA (HyttfHud
( 'oial</ia) , HV.SILRIV (Infantih) , LUMBAGO
Coxa Vara. — AdetonmU duetomcuiva-
tion of the neck (01 nppei put of the shaft)
ot the femur, (haiacteiised by stiffness ot the
hip, limping, shoi toning of the limb, piommeiue
ot the tioi banter and displacement ot it abo\e
NelatonVt line, and diminution 01 loss of
abduction »SVe DEIOKMIHES (Lty and Thtff/t,
Com Vaia) ('nt ft \rah/a is iilso .1 defoi inity of
the neck of the temin, but in this c.ise theie m
loss ot adduction tfi<?<t/w HiP-JoiM, Tviunits
OF (Cojni Vnta) , Hip- JOINT, DI&E\SKS or
(Z>tr/f//»os/s) , KTCKEIS (Cltmcti
COXltlS. -Inflammation of the hip-joint
,SVf DEboUMlllhs (Coni/enttol J)i«lntatioH, of Jfip,
Diayncw*) , HiP-JoiM, DISEASES 01 , RHEUMA-
TISM, KHEUMAIOID AlllHKirih
Cracked -Pot Sound, fr? BRUIT
(Jit utt de jtot frit) , PNEUMOMA, CUXIC&L (Physi-
cal ,S'/f/>w., Red J/ejM twttwn)
Cramp.— Spasm of a muscle or group of
muscles, accompanied by pain, it M common
UH a neuiOHis of profession or of employment, as
wntei's ciamp (scrivener's palsy), pianist's
cramp, tailor's cramp, hhoemakei's cramp,
telegraphist's cramp, milkmaid's cramp, motor-
ist's cramp, coachman's ciamp, etc, etc See
AIXJOHOLISM (Motor Variation-*, Spasm), CHOL-
ERA, EPIDEMIC (Symptom*, Ctampi) , DIABETES
MELI ill's (Net wits System), (»ou (Acute,
Pi emfmition1*), ( JOIT (In fi/ulai, Net vow System),
MUSCLFS, DISEASES OF (VaMitlai Duturfatnce) ,
SPVSM (I'hi/uolo<jt/, damp), SroM\cn AND
DUODEMM, DISEASES ((*eneta( Symptomatology,
Remote Symptom*) , TEIAN\ (Jfoto* tiymptoms) ,
THYROID (\\ ANI>, MA.DICAL (Exophthalmic Goitre,
Net voiit> Symptom*)
Crania Pro^enea. See C'IUNIUM
PjMH.li.MUM
Cranial Nerves. See EUAI\, Pmsro-
LO(f^ ot (Cmmal N<t »(rs) , PH\MOIXJ(T\, NERVOUS
Si si> M (Mttlvllit Oblontfata and ( 'tanial Net ves)
See aho NOSE (fot Fn*t Ntiw), KEIINA AND
OPTIC N*HVK (fat Sicond Nrrve) , OCUI^AK
MUSCIL^, AIIWIIONS or (iot Third, Fouith,
and Snth \tiwx), Finn Nhinif, AFIHTIIONB
or, FACIAL N&HVF, PAHAMMS (pn Seventh
Netre), AiDrioin XRRVE A\D LAB^RINIII (for
Etyhth Net ut) , (.JLosso-PiiARVMiFAL NERVE (for
Ninth Netve) , VAJ.US NERVE ( fo? Tenth Netve) ,
SPINAL AKLSNOUY N>R\h (foi Eleventh Netve) ,
HYPCM.I O.SSAL NERVE ( tot Twdfth Nnve)
CranlO-. — In compound \\orrls nanio-
((ii kpaviuv, skull) signifies relating to the
skull CtntufLtomy, foi instance, is icmoval
of a piece of the cianial vault to allow giowth
of thcbiam, aanwrlmt is a head-ci usher and
extractor, used in obstetnes, ha\mg a solid
blade uhich is passed inside the c'lanium, and
a fenestiated one \\hich is apjihed outside (tee
LABOUR, OPEH \ i IONS, £mfa i/otomy) , namometry
is the science of measuring ciama c/amopaffun
is a teratologic.d t}pe ot double monstei in
\\lnch the t\\ms tue united by the heads, the
union being eitliei by the occiputs (miopagus),
01 by the frontal legions (metopagub), or by
the sinciputs (acrocephalopagus) , the nanio-
phaiynr/tal canal is a passage leading (in the
embiyo) fioin the phaijnx through the b]>henoid
bone into the ciamum, and is a lemnunt of the
dneiticulum of the pituitary body , craniov/naia
is a ilefeetive (<yVi 1) state of the cranium in \vhich
the brain is exposed , tianio«te{/not>i'* is contrac-
tion of the skull , ctaHwttow is premature
ossification of the sutuies of the ciamal vault,
mm iota tn* (01 ctaniomalaua) is a morbid con-
dition (laclutu) of the cranium in which the
vault bones (especially the oc( iput) are thinned
in places and gue a sensation of yielding or
crackling to the fmgei (*ee BONK, DIHEAHKS,
Inhftited Syiththt , KKKEIS, Clinical Featmen,
Head) , namotomy is the o])onttion of perfoiat-
ing the cranial vault so as to diminish the size
of the cranium in dithcult cases of labour (see
LABOUR, OPERATIONS, Enilnyotwny)
248
CRANIUM
Cranium. See BRAIN, SURGERY OP
(Trephining) , INSANITY, PATHOIOGY OF (Patho-
logical Anatomy, The Slull) , LABOUR, DIAGNOSIS
AND MBCHANISW (M&uhhny of the Foetal Haul) ,
PHYSIOU>OMY AND EXPRESSION (Cranium) ,
SCALP.
Cranium Proffenlum.— Aimoimai
projection of the lower jaw, due to increase in
its size or to defects e growth of the uppei jaw,
with narrowing of the face, etc tee INSANITY,
PATHOIOUI OF (Skull)
CransaO. Ntf BALNKOUKI\ (Fiance,
Calcareous}
Crapulence.— Intempeiante in eating
or dunking, and the effects of such intemperance
(Latin, crapufa, intoxication, Greek, Kptuirdty,
a drunken headache)
Crasls. — (Constitution 01 temperament
(Gr Courts, mix tin o)
Crassamentum. — The thick, jelly-
like part of coagulated hlood, consisting oi the \
blood coipuscles and the fihnn , the clot (Latin, I
crassare, to thicken)
Cratomanla. — A form of insanity chai-
aotenscd by the mania of po\ver or superiority
(Gi K/WTOS, strength , pavia, madness)
Craw-Craw. Kee KILAUIAMS (Film in
Peistani) y SKIN DISEASES o* THE TIIOPK s ($km
Diseases of Jiactnia! Otiffin, Ctaw-ctaw) — A
parasitic skin disease oi West Afuca (Dutch,
kraauwen, to scratch)
Cream. See DIET (Milk and i1v Product*) ,
INFANT FEEDING (Attijuial Ferdtny, Cream),
INVALID FEEDING (Fowl tor the Ayetl, Ahlk awl
Cream), Mnx (Difteti<) , Pmhioixxn, Fcxin
AND DiUhMioN (Btittet and Cream)
Cream of Tartar, s* PUTAHH AM>
ITS SALTS (J'otawi Taitia\ Aeulw)
Creamery. «s'« MUK (industnai,
Creameiy)
Croat.- Indian chnetU or Androqiaphiv
pamculata flee ANDKOGU \PIIIS
Creatln. — An alkaloid 01 extractive
(methyl-guamdm-aeetic at id, (\H0N,02) occur-
ring in muscle, and excreted in the mine in the
form ot c»Mf/Mfji (0,H7N,O), which is creatin
which has lost a molecule of water Creatm-
(rmia IH the moibid state ascribe i to excess of
creatin in the hlood Set Pmsioixwn, TISSUES
(Chemittty of JA««< fe, JSxtt actives) , Pn\ SIOLOUI ,
THE Ricxiii (Plnwn awl Serum), PHYSIOIX)O\,
FOOD AND DlUKSIIOK (Flesh) , PHlSIOIXXiY,
EXCRETION (Uttne, Xittogeiwus Substances,
Creatimn)
Credi Method.— (1) The Credo method
of placental expiession is carried out by seizing
the fimdus uteri (through the atxlommal walls)
with both hands and squeezing it firmly down-
wards and backwards towards the pelvic inlet
(2) The (/rede prophylactic treatment of the
eyes of the child at birth consists in dropping
one 01 two drops of a 2 pei cent solution of
silver nitrate into the con j vine tnal sac of each
eye , in this v\ay the nsks of ophthalmia neona-
toium have been greatly lessened, but it is not
nccessaty always to use the mhci nitrate solu-
tion, boiacic lotion oi distilled water may suffice
CredulitaS. — The condition of being
easily duped 01 pei minded , regaided as a
variety of moria imbecilis 01 idiotism
Creeping Eruption.— Lai \ a
a skin eiuption, chaiacterised by a taised led
line which may travel quickly o\er the Iwxiy,
due to the larva ot the hoise bot-H} ((ra
eqni) , deimamyiasis hneuns nngi.ins
" Creeps." — Kvtraoidmar^ restlessness
and imtabiht}, witli \\akeiulness, diy skin,
thirst, and the sensation of fulness in the limbs,
due to fatigue (bodily 01 mental), etc , the
"hdgets"oi dysphona
Cremaster. — The suspensoiy musde of
the testicle, having (in the human subject) only
slight power of dialing that oigan up towards
the inguinal c.uial, the name is derived from
the (jreek K/>epxi', to suspend
Cremation. — The i eduction of the corpse
to ashes by binning in a close fuinace , tin*
mode ot disposing of the dead, which is piefci-
able to eaith-bunal, if propeily earned out,
Heems to have been fust practised in Kin ope
(in Italy) in 1869, the (Vernation Socit-t\ of
Kngland was foimed in 1874 \\ith Kn Hemy
Thompson as its hist president, and, after some
legal difficulties had been ovcicome, a cicma-
tonum was established at Woking and ciern.it ion H
successfully (an led out, a Ciemation Ait was
pissed in 1902, and there ate now ciematoiia at
Glasgow, Manchestei, Liveipool, Birmingham,
Hull, Leicestei, Hendon, and Darlington, as well
as at Woking , the fuinace used may be oithei
reverberatoiy (a flame placing on the dead bod^)
01 legenciative (gas from coke luing burned in
the chambei), and the whole process can l>e per-
foimed in less than two hours , the cost is still
considerable, but could be greatly reduced if the
practice of cremation weie common It has been
feared that this mode of getting rid of the dead
body might check the detection of crime, but
with pi ope i precautions this is unlikely
Cremometer. — A graduated cylmdei
showing the percentage of cream rising spon-
taneously to the surface of the milk See MILK
(JSjifimt nation)
CREMORA
249
Cremora. — Pharmaceutical preparations
(for external use) containing glycerine or vaseline
as a basis ; creams (Latin, cremor, milk), such as
Hazeh>ne Cream (B \\ and Co )
CreOlKn. — A dark syiupy liquid, obtained
from the dry distillation of coal, consisting
largely of coal tar, fatty acidn, and resins, and
forming a white emulsion with water, it is
goimicidal and is therefore used as an antiseptic ,
it is contained in Jeyes1 disinfectant
CreOSOtal. — (\irbon«tte of cico'sote, an oil
sometimes used in place of cieosote and in the
same dose , it is not so likely to produce indi-
gestion. See CREOSOTE
CreOSOte. See BRONCHI, BHOXCHIECTA.SIH
(Treatment, Cteowte) , LUNO, TUBERCULOSIS
(Tr&itment, Cteosote and it* Congeneti) , PHAR-
MACOLOGY , PRESCRIBING , ToMTOIXMlY (On/tlHU
Poison*, Cieowte) — Cieosotum ((Jr ikpeus, ilesh,
and rr«feii>, to proseivo) or creosote is an
oily liquid, with a peculiar smell, obtained by
the distillation of wood tar (Pur Ln/utf?a),
and consists of a mixtmo of ciaowl (08H]0O2),
crevtl ((17HS0)> ojyneiof, niethylo eio/, t/uauuol
(C/71ISOJ)| etc (Creosote from coal Ui differs
from the abo\e in ccitam particulars ) Creosote
is incompatible with oxide of silvei, forming
with it an cxplosiM* mixtme The dose of
creosote IB 1 to 5 in , and the ding is best grven
suspended in miu ilage, as a pill, or in capsules
(diluted \vith almond oil) The official piepaia-
tions aie the Mntuta Cteowtt (dose, \ to 1 fl
oz ) and the Untfuentnni (Jieouttt The drug is
useful in obstinate \omiting, in some forms of
dianlura, m typhoid fever, and in feimentative
dyspepsia, acting as an antiseptic, it is also
slightly an.csthctic and styptic, and has been
commonly used in tooth.u he (cotton-wool plug
soaked in it being applied to the tooth) Of late
yeais it has been much lauded as a lernedy in
phthisis and hionchicctasis, as an inhalation
CrepftUS. — The grating or crackling
sound or feeling pioduced when the ends of a
fractuied bone are nibbed togethei (during
manipulation) Crepitant lales are the oinck-
ling sounds heard ovei the lungs m pneumonia
See FiiArruitKH (Method* of Emmtnativn) ,
PNMJMOMA, CLINICAL (Phywal Siynt>)
Crescent Bodies. See MALARIA
( Main rial Pa t a « te)
CreSOl. - Tolyl alcohol (C7H7OJI), one of
the hydroxy toluenes, found m thiee isomeric
forms (oithocresol, metaciesol, and paracresol)
Cresolsulphomc acid (CJI4(S03II)CH3) is formed
from it bv the substitution of the molecule
S02OH for" hydrogen.
Crest. — A ridge or crest or i id go -like
structure, such as the crest of the ilium or of
the tibia.
Cresyl. — The radicle of cresol (C7H?)
or methyl - phenyl Ciesol is regarded as
crcsyhc acid, ciesyl alcohol lias the formula
DIAGNOSIS
MORBID ANAIOM\
Greta. See CALCIUM AND ITS SALTS
Cretan Fever. £MUNDVLAM FEXBB,
Cretinism.
249
250
250
251
251
RKSLTT 01 TREAIMKM 251
See r//w HB\D (in Ctetinmn) , INSANIT\,
OF (Etivloqiral Viinetien), THYROID
MRIIIIAL (Tin youtcctamy) , MENTAL
(Ctettnou? Case*) , SLEEP, NORMAL
AND MoHHii) (Mnrbul NomnolcHrc in Cietin*)
DEHNIIION — Ciotmism (congenital niyxcrdema)
is the peculiai condition of artcsted Inxlily
and mental growth and development, \iith in-
creasing deformity and dcbihtx, \\lneh results
from a congenital deficiency of thyroid secretion
due cithei to absence of the gland or to some
morbid change interfering \i ith its function
The name is also geneially, and peihaps con-
\enicntly, applied to the cases uhcic defective
action of the thyroid begins in eaily childhood
(juvenile mj vu-dema)
(Lvus \TIOV - - That the essential cause of
cietimsm is deficiency of the th)ioul scciction
is now an accepted ftict The morbid influences,
however, \\hidi le.id to disease 01 atrophy of
the tht>ioid inland, and thus abolish its secietion,
are still to a laigc extent unknown They are
probably different in the endemic and sporadic
f 01 ins of the disease
Endemu actmiwi is goneially met with in
mountainous distucts It is always associated
in distribution with endemic goitie, and a large
proportion of deaf and dumb eluldien are found
in the same districts and families The cause
of these tlnce conditions is evidently the same,
and is known to be piesent m the drinking
water It is, in all piobabibty, a mu ro-orguuism
(Kochci), Klthough this has not yet been ab-
solutely punod
All inqunies into the pnmaiy cause of tpotttdic
cretmiMi ha\e hitheito had only negative results
The disease veiy often occuis in Luge and other-
wise healthy families Two 01 moie cases are,
however, sometimes found in one family, and it is
also not very uncommon for cases of infantilism,
achondroplasia, and othei forms of d waiting to
bo piesent among the bi others and sisters
In cases of juvenile myrwdema there is often
a histoiy of one of the infectious diseases having
occuired shoitly before the symptoms were
noticed
DISTKIBLTIOX — Endemic cretinism is almost
250
CliKTlNISM
unknown in (ireat Britain, hut a few cases
are to lit: met with, especially in Derbyshire,
Somersetshire, Yorkshire, and Westmoreland.
It occurs to a considerable extent in the moun-
tainous regions of Kit rope, especially in Switzer-
land, r-' ranee, and Italv, and has been reported
as prevalent, in various parts of Noith and
South America, (-hina, India, Madagascar, etc.
Sporadic cretinism is a comparatively rare
disease, but cases of it have been reported from
nearly every quarter of the world. There seems i
no reason to connect its occurrence with tho
physical characters of the district in which it is
found.
DKSCKII-TION.- -Infancy. — Even in severe cases
of cretinism there seems to be very little wrong
with the child at birth. If the mother is ob-
servant, however, she soon notices that the
babv is backward and apathetic — crying and
laughing very little, and that the bowels are
obstinately constipated, also often that the
tongue seems too large.
On examining the infant cretin we are struck
by his pally, expressionless face and wrinkled
forehead ( Kig. 1 ), and on measurement he is
found to he undergrown, although as yet there
is no noticeable disproportion between the
trunk, head, and limbs. His hands are char-
acteristically broad and short. The temperature
is subnormal. The thyroid is generally absent
in sporadic cases, while in the endemic form
there is usually a goitre.
ChiUhood and Youth. — As the child grows
older his development lags behind, and the
characteristic cretinous appearance becomes
steadily more striking. The
swelling increases in the fact
myxa-dematoiis
and elsewhere,
the belly becomes more prominent, and marked
lordosis develops. There is generally an um-
bilical hernia. Circumscribed fatty swellings
appear above the clavicles and in front, of the.
axilhe. The diyness of the skin increases, and
the hair is very scanty and dry. The i'ontanelle,
remains widely open. The miik-leeth may or
may not be delayed in appearance, but generally
they remain too long in the gum, and they may
all be present even as late as the eighteenth
year. The child's growth and activity are
greatly interfered with, so that at ten or twelve
years old he often has the si/.e and the feebleness.
of a boy of three or four. The menial condition
in an ordinarily severe case of the disease is
that of imbecility, but in slighter forms of the
disease the child seems merely backward. He
is dull and apathetic, slow of movement and of
apprehension, but neat and tidy in his ways,
and docile and quiet, if not teased. Speech is
generally long of being acquired, and the words
used are few.
Athilt Af/r.—'di spite of their debility, cretins
not infrequently live to forty, fifty, or even sixty
years old. The adult cretin shows the disease
in its most marked form (Fig. *2). He is gener-
ally about three feet in height, with large
brachycephalic head, thick dry redundant skin,
scanty coarse hair, and an open fontanelle.
His trunk is stunted, and he has marked lordosis
and a. prominent belly ; there is often also lateral
curvature'. Tlu; limbs are short and thick-set,
with prominent hard muscles. The gait is very
feeble and waddling. The extremities are always
cold. There is little or no pubic or axillary
hair. In the male the external genitals are like
those of a child, while in the female the breasts
remain quite undeveloped. Menstruation is
very late of appearing and very irregular, if it
comes at all. In the few cases in which preg-
nancy and delivery have taken place, the infant,
although not myxaxlcmatous, has been atrophied
or hydrocephalic at birth, and has died soon
after. The cretin's mental condition does not
improve as age advances. Although very dull,
he understands and observes more than ho
appears to, but he has little or no initiative.
His interests are exceedingly limited. He is
shy, morbid, and solitary.
During recent years a number of slighter
cases have been described by Hertoghe and
others as really instances of cretinism, although
they lack many of the usual symptoms. In
these there is little beyond stunted growth,
delayed closure of the I'ontanelle, and some
degree of mental dnlness. The confirmation of
the diagnosis is to be sought in the marked im-
provement which follows thyroid treatment.
I JIAONOSIS. The two morbid conditions most
apt to be mistaken for cretinism are achondro-
plasia. and the so-called " Mongolian " type of
imbecility.
The resemblance which achondroplasic dwarfs
CRETINISM
have to cretins at birth is in sonic ways striking,
but it is (H/u/t cretins they resemble. Tlie ex-
treme shortness of limbs which they exhibit is
not a characteristic of cretin infants, while their
soft natural akin and hair, their normal tempera-
ture and mental condition, and the peculiar
formation of their hands (,sv>- u Achondroplasia '')
enable them to be readily distinguished.
"Mongolian" imbeciles resemble cretins in
their backwardness, their frequently protruding
tongue, scanty dry hair, and dwarfed stature.
They differ in being less stunted in growth, in
their physiognomy, in the shape of their hands,
and in their general appearance and mental
characteristics (.src " Idiocy and Imbecility").
Moitmi) ANATOMY. — In the endemic form of
the disease, goitre is present in about 7-r> per
cent of the cases, while in the remainder the
thyroid is absent.
In most cases of sporadic cretinism no trace
of a thyroid can be discovered ; in a few the
gland is atrophied, and shows cirrhotic changes ;
rarely there is a cystic goitre.
TUEA T.MKNT. --The treatment of cretinism, like
that of adult, myxd'dema, eonsists in the con-
tinued administration of some preparation of
thyroid gland by the mouth. The thyroid of
the sheep is that generallv used, and it may be
given raw or in such form as the Thyroideum
Siccum or Li<j. Thyroidei (II. I'.) or various other
dry preparations. One of the untst reliable of
these, mid one which seldom disagrees, consists
of the dried colloid matter of l he thyroid
(Hutchison). The dose must vary according to
the age, si/e, and strength of the patient, and
according to the intervals at which the remedy
is administered.
The fresh raw thyroid is probably more active
and trustworthy than any of its preparations.
It may be given to a young child, to begin with,
in doses of 11|1. to J of a gland ///•/"- « ivtk \ or
in double these doses to an older child or adult.
After some time one whole lobe may often be
taken each time with advantage. It is a curious
fact that the improvement in cases where thyroid
is given twice a. week is just as continuous and
satisfactory as that seen where the remedy is
administered in small doses daily or every few
hours.
(Generally, however, it is more convenient to
use i>ne of the manufactured preparations, and
to {.iv, ii dailx. In a young infant we may
begin wilh gr. i. of the dried -.rland, in. ii. of
the Liq. Thyroidei, or gr. ! of the dried colloid
matter. Jf these doses cause no unpleasant
symptoms they may soon be increased. In
adolescent or adult patients, from three to five
times these doses may be given daily to begin
with.
During treatment the patient may go about
as usual, and no special diet is required. The
temperature, weight, growth, and general health
must be closely watched. Should the patient
become feverish, and show signs of sickness,
headache, etc., this indicates rest in bed and a
diminution of the dose. Often after some weeks
or months an increase of the dose is necessary
to maintain the improvement satisfactorily.
In treating adolescent cretins it is very im-
portant to prevent, if possible, the bending of
the legs which is apt to follow their greatly
increased activity. For this purpose they should
be made to lie as much as possible.
THE RESULT OF TREATMENT.— When the treat-
ment is carefully carried out rapid and con-
tinuous improvement results. The temperature
rises to and remains at the normal level. The
unnatural swelling quickly disappears from the
face and other parts of the body. The features
i lose their unnatural thickness and become more
j mobile, and the eyes look much brighter. At
i the same time the tongue ceases to be pro-
i truded, the voice becomes less guttural, and the
child no longer snores at night. The abdomen
diminishes greatly in circumference, and if an
umbilical hernia is present it disappears. The
fatty swell ings also vanish at an early stage of
the treatment.
The skin loses its harsh and dry feeling and
becomes soft, and (he cheeks show a natural
Hush. In young patients the hair falls out, at
first, in considerable quantities, but is soon
replaced by a new crop which grows more
rapidly and is softer and often of a dill'e.rent
shade of colour.
At first there is a considerable loss of weight,
with a relaxed condition of the muscles and
; ligaments, but in the course of six months,
252
CRETINISM
if not before, the patient gains flesh consider-
ably. The limbs also become firm and strong,
and the back straighter and more shapely. The
retarded evolution of the teeth is actively
resumed.
The growth of the skeleton is peihaps the
most striking change of all It begins at once
and pioceeds rapidly The patient often gams
2 in in height within the hist two months, and
may make as much as 6 or 8 in in the first
year After th.it the rate of growth diminishes
and appio vi males to the normal The appetite
is greatly increased by the treatment, and the
bowels generally become regul.ii in action The
mental improvement which occurs is apt, at
first, to be greatly overestimated by the parents,
because the child look* so much blighter and
his movements arc so much hvehei than before
Within six months, however, there IH unmistak-
able advance, and this continues and increases
— the better-nourished brain becoming incieas-
ingly capable of work The childien Wome
more inquisitive, more independent and entei-
piising, and moic inclined to do things They
lose their shy, moiose, self centred disposition,
and become bught, happy, childlike, and
sociable
In the milder cases, the arrears of bodily
growth aio soon fully made up, and the state
of the intellect approaches, if it nc\ci quite
reaches, the noimal In a certain propoition
of cases, howevei, while the bodily iccovciy
is more or less complete, the child lemams an
imbecile
In adolescent cases (from sixteen to twenty-
five years) the nnpro\emcnt is \eiy gieat, but
a considerable degice of deformity remains,
owing to the loiter limbs not growing in pro-
portion to the lest of the bod} Thetc is also,
at this age, a stiong tendency for the lei^s to
become much bowed, and this is evticmely
difficult to prevent
In adults (aftci about thirty) the effect of
treatment is much less In them theic is
usually a growth of one or two inches dining
the first few months, and none aftei The
appearance of the fate impioves greatly, men-
struation becomes moie 01 less regular, and the
breasts enlaige Even at this age, howevei, the
ticatment IH advantageous because of the gicat
impio\emcnt which it causes in the patient's
geueial health, and especially in his happiness
Although he still icniams a child in mind and
a dwarf in body, he begins foi the first time to
take an active pleasure in seeing and doing
things and in associating w ith other people
Creyat. See ANDROURAPIIIH
Cribriform.— Sieve -like (from Latin,
m&rnr«, to sift), perforated with numerous
small holes, ey the cnbnform plate of the
ethmoid bone.
CrlCO-. — In compound words crico- refers
to the cncoid cartilage (Gr K/H'KOS, a ring, and
&Sos, resemblance) of the larynx, eg crtco-
arytenotd (relating to the cncoid and aryteuoid
cartilages), crico-hyoid (relating to the cncoid
caitilage and the hyoid bone), cricotomy (open-
ing into the laiynx by dividing the cncoid
cartilage), etc /fee LAIUNX, AFFECTIONS OF THE
CARTILAGES, PIIYMOLOQI, RESPIRATION (Voice)
Criminal Responsibility. See
also UNCONSCIOUSNESS (Double Consciousness)
— In holding a person responsible (i e liable to
punishment) foi his misdeeds the law rests on
two assumptions or postulates legaidmg human
beings These are (1) that the individual can
distinguish between "light" and "wiong" in
the concrete case , and (2) that he is possessed
of will-power adequate to contiol his impulses,
and to contiol them in the light of that know-
ledge of light and wrong The law piewmei
these capacities to be piescnt — piesumes a man
to be wine accoidmg to this standaid Wheie,
howcvei, it can be established that, owing to
mental infirmity, these ca]>acities, or cither of
them, are lacking in any individual, the geneial
nilc of icsponsibihty is lelaxcd If a criminal
act be unmistakably the lesult of invtntty in
the perpetratoi, the accused is held to bo not
icsponsible thercfoi
The decision of the question \vhethei an
accused person is, on the giound of insanity, to
be exempted fiom responsibility foi an act \\ith
which he is charged, is, of couise, the function
of the ]ury, undei dnection of the judge But
it is the duty of the medical expert to assist
them in coming to a right veidict in the tnattei
It is the purpose of the picsent article merely
to indicate, for the guidance of medical wit-
nesses, the standpoint from which the matter
will be investigated judicially by setting ioith
the geneially accepted criteria of legal insanity
This ai title does not attempt to follow the con-
tioversy between medical and legal authouties
as to what degree or what forms of mental
deiangement ought to exempt from responsi-
bility foi crime
The authoritative statement of the law of
Kngland bearing on ciimmal icsponsibihty is to
be found in the answers of the supreme judges
to the questions submitted to them by the
House of Loids in 1843 (commonly known as
" The Kules in MacNaiighton's Case," 4 AV Tr
N S 847) The le.uling feature in these rules,
as compaied with the views previously enun-
ciated by legal authorities in England, was the
repudiation of a knowledge of right and wrong
merely in the abstract as any test of sanity, and
the substitution of the question whethci the
accused at the time of the act was labouring
under such a defect of reason from disease of
the mind as not to know the nature and quality
of the particular art he was doing Baron
CRIMINAL RESPONSIBILITY
253
Hume (m hia Scottish treatise on Crimes,
i. p. 37) had put the matter thus " The ques-
tion must be relative to the particular act done,
and the accused's knowledge of the situation in
which he did it Did he as at that moment
understand the evil of w hat he did Z WOH he
impressed with the consciousness of guilt and
fear of punibhment 1" The English judges
followed the Scottish authorities by laying it
down that the inquiry must be dnected to the
accused's mental state in relation to the particu-
lar act done
To establish a defence on the pound of
insrinity, therefore, it must bo clcaily pioved
that at the time of committing the act the
accused was labouring under such a defect of
reason, from disease of the mind, as not to
know the natuie and quality of the act he was
doing , or, if he did know it, that he did not
know he was doing what was \vrong "If the
accused was conscious that the act was one
which he ought not to do, and if the act was at
the same time contraiy to the law of the land,
he is punishable "
If a pei son under an insane delusion as to
existing facts commits a criminal oftenee in
consequence theicof, he is not necessarily freed
fiom icsponsibihty on the giound of insanity
Much depends on the natuie of the delusion
The accused's lesponsibihty is to be determined
by consulting whether, assuming as. leal the
facts with regaid to which the delusion exists,
theie would or would not be legal justification
lor his conduct Thus, if undci the influence
of his delusion he supposes anothei man to be
in the ait of attempting to take away his life,
and he kills that man, as he supposes, in self-
defence, he \\ould be exempt from punishment
If, on the other hand, Ins delusion was that a
in<in had only in j mod him in leputation 01
fortune, and he killed him m icvenge for such
supposed mjuiy, he would be liable to punish-
ment This statement of the la\v given by the
English judges has not commended itself to
medical men As a test of responsibility it
appears to be vitiated (as Di. Maudsley points
out) by the assumption that a man, having tin
insane delusion, has the po\vcr to think and act
in regaid to it teawwiMy , that at the time ofr
the offence1 he ought to have and to exercise the
knowledge and self-control which a sane man
would, were the facts with icspcct to which the
delusion exists real It, however, stands as
authoritative in the law of England , but, for-
tunately, it has not been very logically applied
in actual cases Its corrective is probably
supplied by the more general rule of leferenec
in each case to the accused's knowledge of
right and wrong in regard to the particular act
In Scotland, on the other hand, it has been
judicially recognised that a man may be en-
tuely insane, and yet may know well enough
that an act winch he is doing is forbidden by
the law of the laud. If a man have not a
sane mind to apply his knowledge, the mere
intellectual apprehension of an injunction or
prohibition may stimulate his mind to do an
act simply because it is foi bidden, or not to do
it because it is enjoined (Lord Moncrciff m case
of Miller, 1874, 3 Temper's Report*, 16)
The " Rule* in MacNaughton's Case " do not
deal with the subject of ftioial infinity For
long the Coints rigidly refused to recognise
such foitn of mental derangement ttutmwal
insanity (meaning b} that term mental de-
rangement in which disorder of the moral
faculties is more pionoimced than disorder of
the intellectual) is now undoubtedly accepted m
the British Courts as freeing from responsibility
or mitigating punishment accoiding to the
cncum&tances of the case Fuither, weakness
of niinsl of a lesser degiee, not such as to free
entirely from lesponsibihty, is held either to
wariant lemeiuy in punishment, or, it may be,
to justify a xerdict of something less than the
full crime ehaiged, e (j of manslaughter or
culpable houmidc instead of mmdci
If insanity be pioved, the question of ic-
sponsibihty is not affected by a consideration of
what was the raw of the disoidei. The fact
that it was occasioned by accused's own acts
(di unkenness or other excess) is not of con-
sequence Intoxication docs not free from
Responsibility , insanity bi ought on by drunk-
enness will When a person killed another
under a " momentaiy hallucination induced by
di unkenness," it was laid down in a Scottish
case that the juiy might acquit of murder and
convict of the minor ciime of culpable homicide
(Robertson or Brown, 188(>, 1 W lute's Report*,
93)
1'iescntly existing insanity may bai criminal
proceedings, befoic, .it, 01 after trial In such
a case it is, of course, the present mental con-
dition of the accused that the medical witness
must speak to , and thercfoie an examination
of accused ought to bo made as shortly as
piacticablc before the mquiiy — on the same
day, if possible In Scotland, where insanity is
pleaded in bai of tual, the tacts to be estab-
lished (betoie a judge without a jury) aic that
the accused is presently insane, and incapable
of giving intelligent mstiuctions foi his ciefencc
Criminology. — The scientific study
of the physical and psychical characters of
criminals, criminal antlnopolouy tiee Aisoit-
TION (Jfe<fi<tj-Leynl Aijjfct*) , ANTHROPOLOGY ,
ANTHROPOMETRY , BERTH J.ONAOL , MEDIC-INK,
FORENSIC (Identity) , MEDICINE, FORENSIC
Crisis. — A paiovysm of pain (gastric, hepa-
tic, nephritic, etc ) occuning during the pro-
gicss of locomotor ataxia, or a sudden change
in the comae of life (e </ at pubcity or at the
menopause), or during the adxance of a disease
254
CRISIS
(e.g. rapid defervescence m the course of a
fever). See LYSIS , PNEUMONIA, CLINIC \L (Clini-
cal Featwes) , TABEH DORSALIS (Symptoma-
tology Urethral, JilaJder, Renal, (fasti it, In-
testinal, ami Rectal GWi) , TEMPERATURE (Fever,
Defervest enre) Lumbar pain, in cases of mov-
able kidney, has been termed Dietl's cnsis (7 v )
Crlspatlon. — Feeble muscular twitch-
ings , the " fidgets " or " deep's '
CrlSta. See CREST
CfOCUS- — Saffton or (!tocu* consists of
the stigmata and styles of Ciocm mtivus, and
contains crocm (a glucoside colouiing matter)
and a volatile oil , there is an ofiiu.il Tinctaia
Croci (dose, 5 to IT) m ), and its chief use is as
a colouring mattei (e </ m Tinctura Cinchonao
Composite) See PRESCRIBING
Croft Spa. See B\LNEOLOGY (Gteat
Britain, YotMute, Sulphut Wateis)
Cromblev8 Molar Ulcer.— An ulcer
which f 01 ins tatweeu the last t\\o teeth in the
upper or lower jaw m the early stages of sprue
See SPRUK (Clnwal Featmts)
CrO88 Birth. See LABOUR, DIAGNOSIS
AND MECHANISM (Timiwerw Lie*} , LABOUR,
OPERATIONS (Veinon)
Crossed. — The name applied to some
moibid state (erj paralysis) occumng in the
opposite half of the Inxly 01 of an organ to that
in which the lesion pioduung it is See BRAIN,
TUMOURH OP (Diaynovs, Ifafional, Pons) , HIP-
JOINT DISEASES (flthitftal, Ciowd-Leif De-
foimitt/) , OCULAR MUSCLES, A*FECIIO\S OP
(Paralysis, Double Vision)
Crotal Idee.— The pit vipeis See SVAXJC-
BIIES (Classification)
Crotchet. ---A bharp hook on a stem,
passed inside the perforated skull of the fcvtus
(in embryulcia) and used as an extractoi ,
"crotchet cases" are ciamotomy cases See
LABOUR, OPERAIIONS (Emtoyotomy)
Croton Oil. S<e also DERMATITIS TRAIT-
MATJCA ET VE VENA PA (Cauvtl Agents, VefjctaMe) ,
DRUG ERUPTIONS (Type*, Papular, Vesicular,
and Pustulai) , PHARMACOIAJGY , PRESCRIBING ,
TOXICOLOGY (Aborti^arientt) — A fixed oil ex-
tracted from the seeds of Croton Tiglium. It
is biownihh in colour, has a faint rancid odour,
and is intensely irritating. Dose — i-1 m
Preparation — Limmentum Crotoms. " Kxtei-
nally ctoton oil has been used as a counter-
irritant in diseases of the chest and in joint
affections, but it causes seveio pustulation and
even skin destruction, and is now seldom em-
ployed As a last resource it may lie applied
to destroy an obstinate patch of ringworm of
the scalp. Internally it has a violent purgative
action and is usually given on a lump of sugar
or mixed \\ith butter It is recommended m
apoplexy and other conditions m which the
patient is unconscious and unable to swallow,
but it is pieferablc in the majority of such
cases to admimstei jalap or other common
purgative through a tube passed into the
oesophagus
Croup. — The name given, somewhat loosely,
to lai^ngitis with or without hbrinous effusion,
us \vell as to spasm of the glottis See DIPH-
THERIA, LAR\NX, ACUTE AND CHROKIC IM-LAM-
MAFIONS (MeHifanwjut Latynyitis) The toim
cioupom may bo used in the above senses , it is
sometimes employed also for any membiaiious
exudation, diphtheritic 01 not See CONJUXC-
TIVA, DISE \SKS OF (Memltnmous Ophthalmia)
CrOWborOUgtl. See THERAPEUTICS,
HEM.ru REPORTS (En</li*h, *S'u*«7)
Crowning. — The stage in labom \\hen
the veitex (01 ciown) (»t the head appeals at the
Miha, and is sunoimded by tho ciicle ot soft
paits (the labia and peiiueum) as b\ a iiovn
See LABOUR, DIAGNOSIS AND MKCIIAN'ISM (Vntej.
Case*, Extension of Jfeaft) The coxeniiif ot an
old tooth uith a gold 01 poiLolain clown See
TEETH (Hudge and Jiat Wtttl)
Criira. See CHUS (pluial, win a)
CrUS. — The leg 01 thigh 01 any leg-like
striutinc Thus nutal phleumava is phlotf-
iiitisiii of the louci limb following thiombosis ,
the tuna cenhn aie the 1>uudles oi white sub-
stance w Inch form the peduncles t>f the ceiebnun ,
so also m ctuia penis, ciuia clitondis, (ruia
oerebelli, cruia diaphia^nifitu a, etc The (imal
anyina of Walton is intciniittent lameness due
to aiteno- sclerosis , it is the dyhbasia angio-
sclerotica of Eib
CrilSta. — A haid, diy foimation foiming
an outei co\eriiig fin the suiface of the bod),
usually composed of the pioduuts of a skin
disease, a scab, ciutfa lactea 01 "milk ciust"
is the scab often seen on the face of infants
suffenng fiom seboirhwa 01 ec/ema
Crutch. See BEIMIALTFR
Cruvellhler's Palsy. — Piogressne
muscular atiophy 01 jxjhomyehtis anterior
rhionica See PARALYSIS (With Atrophy of
Mwrles)
Cry. — As a sign of disease, more especially
in young children, the cry has considerable dia-
gnostic importance See CHILDREN, CLINICAL
EXAMINATION OF (Respiratory System, The Cry)
The animal-like cry at the commencement of an
epileptic fit (see EPILEPSY, "Epileptic Cry",
HYSTERIA, Diagnosis) is very characteristic , the
CRY
255
" hydroccphahc cry1' is heard typically in
tuberculous meningitis and other cerebral
diseases of children, the cries in a hysterical
convulsion come on later than in an epileptic
one (nee HYSTERIA, Hyvtei icnl Con vulsions)
. — A moibid degree of
sensibility to cold (Gr K/OI'OS, cold), the anto-
nym is c» yancrttheaui, a moibid dcgiee of
insensibility to cold
CrymOSeS. — Diseases ascribed to the
action of cold (Gr K/>I>/AU?, chill)
CrymOtherapy.— The use of cold as a
remedial or theiapeutic agent
CryOSCOpy. »S'e« URINE, PATHOLOGirAL
CHANGES IN (General Pt optics, Ft eeztng-pomt)
Mee aho DECIILOUINAIION , IONIC ACTION , OS-
MOSIS , etc — By ciyoscopy (C«i K/>UO«, frost, and
tTKOTrctv, to examine) is meant the determination
of the hee/mg-poiut ot a fluid The method has
chieily been ap])hed (in medicine) to the blood
and urine, but .my solution ma} be examined
by this means, whu h affords a measure ot the
osmotic pi essm e THKORFTICAL — Ac coidmg to
Van't Hott's thctny of whifumi, substances 111
solution behave like gases, the dissolved mole-
cules exciting piessuie on the walls of the
containing vessel in their eftoits to ditluse
thiough as huge :i space as possible This
owutfic presvine, which can be measuied dneetlv
by a manoinctci , depends (I) on the nature of
the dissohed substance, (2) on the temperatuie,
und (3) on the cunt initiation At the same
tempeiatuie, the osmotic picssme of solutions
of non-electiolvtes is pioportionate to the
numbei of contained molecules, equi-moleculai
solutions exerting the same osmotic, pressure,
but in the case of electrolytes, Mich as suits,
bases, and acids, which aic pirtly dissoc lated
into ions, the osmotic pressure is proportionate
tothenumborof molecules + lonsin solution Thus
a 5 per cent solution of sug.u (non-electiolyte)
exerts only half the osmotic piessuro of a 1 pex
cent solution, but a 5 pei cent solution of sodium
chloride (electrolyte) exerts more than half the
pressuic of a I pei cent solution, because in the
latter case relatively mote dissociation occurs in
the weaker solution, and there are therefoie
relatively nioio ions than in the stronger The
similarity of the laws goveimng gases and solu-
tions is shown in the following (Koianxi) —
Gases.
1. At a constant
temperature the pres-
sure is proportionate
to the quantity of gas
m a unit of volume
Solutions
1 At a constant
teinperatur e the osmotic
pressure is proportion-
ate to the quantify of
matter dissolved in a
unit of volume, t.e to
the concentration
Gases
2 At a constant
volume the pressure is
pioportionate to the
absolute tempeiatuie,
irrespective of the
natuie of the gas
3 At the same tem-
peratuio and piessure,
similar volumes of
different gases contain
the same numbei of
molecules
When a giam-molc-
cule of an} gas occupies
the spice of 22 35 litres,
it exerts at 0 C a
pressure ot I atmo-
sphere
4 The pressuie of a
mixture of gases equals
the sum of the pressures
ot all
Solutions.
2 At a constant eon-
centiation the osmotic
pressure is proportion-
ate to the absolute
temperature, irrespect-
ive of the natuie of the
dissolved substance
3. At the same tem-
perature and osmotic
pressure solutions of
different substances
contain the same
number ot dissolved
molecules in a unit of
\ olumc
An}' solution which
contains one grarn-
molccule dissohed m
22 13 litres exerts at
0' 0 the pressure of
one atmosphere
4 The osmotic pres-
sure of a solution of
different substances is
the sum of the osmotic
pressures ot all
The fiee/mg-point of a solution is lowered,
as compiled with that of distilled \vater, pro-
poitionatcly to the numbei of molecules (or
molecules + ions) it contains ; hence trorn it
the osmotic piessuie can be estimated Now a
giam-molecule dissolved in 22 13 litres has an
osmotic pressuie of 1 atmosphere, hence a grain-
moleeule in 100 cc will have a pressuie of
221 3 atmospheies, and it is found that this
lowers the fiee/mg-pomt by 18 5° C1 — in other
woids, a low CM ing ot the f i ee/mg-point of the
solution by T is equal to just about 12 atmo-
spheies of osmotic piessme
Foi practical pm poses, since in medicine we
are dealing with fluids containing dissociable
molecules, and are concerned only with relative
var rations, we do not expiess the osmotic
pressuie in terius of dissolved molecules or
m atmosphere*, but take the freezing - point
as a standard — the lowei it is the greater
the concentration of molecules or molecules
+ ions
Technique — Beckmann's cryoscope, 01 one of
its modifications, is generally employed It
consists of a tube (a) which contains the fluid
to be examined, and is closed by a doubly
perforated cork through which a metal stirrcr
(6) and a thermometer (e) reading to ^s° pass.
The tube (a) has a lateral opening (d) and is
enclosed in a second tube (e), the intervening
air space acting as a non-conductor and prevent-
ing too rapid cooling The whole is immersed
in a larger vessel (f) containing freezing mixture,
also provided with a stirring rod (g) and a cover
(h) The thermometer employed has a range
256
CRYOSCOPY
of from - t° C to I3 C or theieby , it must be
carefully calibrated and requires to be standard-
ised from time to time \vith pure distilled water
which freezes at zero The accuracy of its scale
may be verified by <i 1 per cent solution of puic
sodium chloride, which freezes at -589° C
Any eriors detected must bo allowed foi in
subsequently using the installment In making
an observation the outer vessel is filled with a
freezing mixture, which should not be too cold,
-3° being a desirable temperature Five or
ten cc of the fluid to be examined is now
placed in the tube, which is then introduced
into the freezing mixture The fluid must bo
kept in gentle, constant motion during the
observation The mercury will bo seen to sink
steadily below tho freezing-point, and then
suddenly rises to a definite point at which it
remains stationary Tins is read off as the
freeiiug-point Crystals of ice begin to form,
and the fluid eventually becomes solid, where-
upon the theimometer falls again
The whole manipulation is one of some
delicacy, and a number of precautions, as well
as a certain amount of practice, are required to
ensure reliable results. The bulb of the ther-
mometer must be completely submerged without
coming in contact with the tube In stirring
the fluid splashing must be avoided. For \ anous
reasons excessive cooling vitiates the results,
hence the freezing mixture should not have
a tempeiature lower than that mentioned.
Excessive cooling may also be prevented by
introducing a minute crystal of ice through the
tube (d) as soon as the temperature falls below
zero , this accelerates freezing without diluting
the fluid, as, of com he, the ice introduced cannot
melt at below 0°
The frec/ing-pomt of human blood is extremely
constant in health, lying between -55° and
-57° C It is customary to express this by
the symbol 8, the minus sign being omitted.
The normal average ficczmg-pomt of the blood
is written 856 To denote the free/mg- point
of the urine A is employed
Giyoscopy of the Hood is chiefly of importance
as a gauge ot tho functional activity of tho
kidneys It has the disadvantage th.it a fairly
laige quantity — 10 to 20 cc — is req uncd In
practice the osmotic pressme of the seiuin may
be legurded as equal to that of the whole blood,
hence the bloixl is allowed to coagulate and the
seium alone IH employed A slight admixture
oi corpuscles is of no moment So constant is
the fi cozing -point in health that variations of
01-02' arc pathological Thus 8= 58 or 59
points to ictention of molecules, while in somo
rases of in«cima a— 65 01 7 In conditions of
asphyxia tho value of 8 is also itused, but falls
to noimal as soon as the blood is pioperly
oxygenated Putting this aside it may be said
that a nso in the value 8 is a sign of renal
inadequacy, and contra-mdicates surgiuil inter-
ference in kidney lesions.
The information which crjoscopy of the blood
aflords in other duections is of minor import.
In pregnancy 8 has a low value, using to noimal
after delivery as the osmotic* piessuie of the
blood returns In hjdi tvmic conditions gencially
the freezing-point is high , in diabetes it w low,
from concentiation of the blood. It is possible
that cryowcopy may yield forensic evidence of
value, since in death from drowning 8 tends
to appioach tho fieezmg-point of the fluid in
which the body is immersed
Ctyowopy o/ the Utine — The chief molecules
influencing tho freezing-point are those which
are most abundantly present, viz uiea and
sodium chloride As dissociation of the latter
takes place after the urine leaves tho kidney the
concentration of the urine cannot be taken as an
exact xneasui e of the osmotic eneigy of the organ.
Fiom the simple fact that A vanes widely in
health, inferences must be drawn with caution,
and as it is practically impossible to obtain the
mine from each kidney separately for anything
CRYOSCOPY
257
but a shoit peiiocl, it will be seen that < ryoseopv
of the urine cannot bo of Mich diagnostic ini-
portancc as th.it of the blood Sahli, indeed,
behoves that it presents few advantages ovei
the estimation oi the specific1 gravity, and states
Ui.it 111 a mine live horn sugai and pioteid A
may be calculated empirically by multiplying
075° C hythelasttwotiguicsofthcsp gr, earned
to the thud decimal place In normal adults A
is gieater than £, avciaging iiom 1 2° to 2 -V in
the mixed twenty -foiu liouis' mine AHei
copious di .nights ot water it may sink to 1°, 01
\uth lestucted mt<<kc of fluid use to 3 3° In
bieast-fed infant* A is usually less than 6, \aiy-
mg fiom 087 J to 45° On the \\hole, in iou.il
nifidoqnoiiry A is low, but ot moie impoitame
is the fart a damaged kidney has lost its powei
of lespondmg to the demands made on it, hence
alteiations ot the intake of \\atei aie not
followed by the notm.il (oiiespondnig variations
IM A The iollowmg figiues fiom Koianyi
illustrate this — In a case of unilateial ])yo
nuphiosis A on the diseased side was 19J, on the
healthy side 1 03 Aftei copious dunking,
\alues of 34' and 08° respecti\ely weie gnen
Hem e the fiee/mg-pomt of the iiinu1 is .1 test of
lenal efficiency only when considered in icl.ition
to the fluid ingested, .ind a low value of A is
significant only when const mt o\ei consideiahlo
jx'iiods ot time If Q = the quantity ot unne
evcicted in twenty-torn houis, QA expresses the
iiiolcculai excretion, and <^(A — 8) the osmotic
enetgy in th.it time A pioduct ccpnxalent to
QA may be obtained by multiplying the last two
figuies of the sp gi by 2 3 5, and by the numbei
ol litre's pissed in twenty-foui houis, which gues
the approximate numbei of giains oi solids e\-
cietod in that time (Sahli)
From the abo\e it will be seen that while in
cryoscopy of the blood wo ha\e a valuable
method of estimating the actmty ot the kidne\s,
the same cannot be said oi ciyoscopy oi tin1
mine In the* piesent state of our knowledge
the iollowmg gcneial statements seem all th.it
are w.manted -o — 56 shows that at least one
kidney is adequate, and justifies surgu al opeia-
tion It 8 = 59 or moie, nephiectoiny is contia-
indicatod, though less senous operations — e r/
nephtotomy — may be peifoimed If 8 =6 01
moie, it IH piob.ibly unsafe to inteifeie until
a moie noimal hguie has been regained When
A is peisistently below H 01 9 it indicates
renal inadequacy , the in mo of each kidney
should be examined separately, or othei tests
(phloi id/iii or methylene l)lue) employed A
comparison of & and A should be made Son
guidance as to the efficiency of the kidney
function may bo gathered fiom the. \aiiations of
A under copious drinking of water and icstuc-
tion of fluid
Ciyo-wopy of other fluids, pathological and
physiological — e y the hquoi ainun and effusions
— has been practised, but the results obtained,
VOL II
though scientifically mteiestmg, have h.id as
yet no piactical outcome
Crypt. — A small cavity, or blindly-ending
tube opening on a fiee surface (ey the crypts
of Liebeikuhn in the intestinal mucous mem-
brane) CryptitH is inflammation of such a
c.uity 01 ciypt
Crypto-. — Iu compound woids rtypto-
T(\ K/»i'7rT(I«,, hidden) signifies concealed oi
hidden
Cryptogenetic Septicaemia
(Lenin) -- (Jenc'ial scptic.cmia oi blood-poisoning
without any appaient local infection dining life,
and sometimes without any discoveiablc lesion
aftc i death , in many c.isc s it is a terminal
infection in individuals wasted by disease, but
sometimes it aflects pel sons apparently healthy,
the* stieptococcus pyogenes is the commonest
nm i o-oi ganism found
Cryptomenorrhoea. Absence of
mensti nation due to stiuctmal anomalies (e y
imperfoiate hymen, \.igmal .itiesia) which cause
the letention of the menstrual blood, hidden
menstruation Afee MEVMIUJAIIOX AND us l)r&-
OUDEUS , LT1EHLS, MAI,H>KMAIIONb OK (CllHtCnl
A yitct s Symjitonin fol<n/y)
CryptOphthalmuS.- The teiatologi-
<al state in which the skin passes without a
hi eak t loin the foiehead on to the c heck, entnely
c losing m the openings oi the orbits , ablepha-
1011 , it is not to be confused \\ith adhesion of
the eyelids (anAylotttjihnion)t 01 with adhesion
of thck palpchial and oculai conjunctival sui faces
Cry ptorchism.—Thctcnatological state
in which one or both of the testicles is hidden,
e </ let, uned in the abdomen 01 aiiested m the
inguinal canals
Crystal I in a. *S'<r SKIN, DISEASES OF
S\\E\T AND SEIJAC-EOUS ()LAM>S (tiuttaaiutn)
Crystalline Lens, fa LENS, CUYS-
•IALLINE, CATAIIACI , etc
Crystal POX. tee YAIUCELI A
Crystals. X?? CiiAitcor-LEM>EN\s CRYS-
TALS, FiCErt (Al* not malting ttlood Crystuli) ,
TEKHM ANN'S CRYSTALS, etc
Cuban ItCh. — A mild form of smallpox,
legal ded by some as a new disease, Philippine
itch
FrUCtUS. Xee also PIIAK-
, PuBSL'KiBiNO , etc — Cubcba or the
diied f i nit of J'ipei culjelnt , the fruits, which
17
258
CUBEB^E FRUOTUS
have a warm, bittei taste, and an aromatic
smell, contain a volatile oil (Oleum Cubebir, dose
5 to 20 m suspended in mucilage), un oleo-iesm,
cubobm (C10H10O,), lubebic acid (('nll,4O7), and
piperinc , cubebs IB given in doses ot 30 to 60
gr., «ind the Tinctura Cubelxr in doses of J to 1
fl dr , the thief action of the di ug is .1 stimu-
lant one upon the mucous membrane of the
gemto-urinaiy tiact, but it is also A dimetit,
and m smnll doses acts as a stomachic , it hnds
its greatest sphere of usefulness in gonorihoja
and cystitis, but it is also employed m bronchitis,
pharyngitis, and asthma (as eigai ettes) Lozenges
of cubobs (Trochisci CuMxr) are othcial in the
U S Ph<n tn.K opeoia
Cubital. — Culnbil, fiom L tufjitus, means
lelatmg to the foreaim, 01, moio paiticularly, to
the ulna, m the ioim of culnto- it enteis into
many compound wotds, such as culnto-caipal,
cubito - radial, etc tiee IAMPHATIP &YSIKM,
PHYSIOLOGY AM) PATHOLOGY (Cllltlffil Gbinilt)
Cuca. tier COCA
Cucurbitaa SeminaPrasparata.
— Melon pumpkin seeds (fiom Cuiurbetn
majLima) 01 popo, m doses of 3 to 4 ox, act as
an anthelmmtic m cases of tape-woim , they aie
given biuised \\ith milk, and aie followed by
castoi oil , they arc oHici<il in the Indian and
Colonial Addendum (1900) to the Biitish Phai-
macopoDia 1898
Culex. — A gnat 01 mosquito See FILARI-
ASIS (Filmia Rancrofti) , MALARIA (History,
Parasitoloyy, The Jfosquito)
Cu I iciCide.— Capable of killing gnats or
mosquitoes
Cultivation, tiee POST-MOUTKM METHODS
(hactei whyicat Investigations, Cultivation),
SKIV, PAWASITBS (Method of Cultivation)
Culture. —A giowth (eg of micro-
organisms) due to cultivation, a purt culture
being a growth m which there is only one micro-
organism
Cumin Fruit.— The seeds of Cuminum
cyminum, aromatic m character , from them is
got cunnc aldehyde or cunnnol (C10H120), and
from it cumic acid (C^II^Og) and cumin alcohol
(C10H140)
Cumulative Action. fa PHARMA-
COLOGY, TOXICOLOGY — When symptoms of
poisoning are suddenly developed in an indi-
vidual who lias been for some time taking a
drug without any evil effects, these symptoms
are ascribed to what is called cumulative action ,
thus, strychnine may be taken for a time in
small doses without producing any unpleasant
effects, and then, without warning, it may cause
spasms, this action may be caused by tapid
absoiption due, for instance, to some transitory
•state of the bo\\el, 01 by diminished excretion of
the ding (eg by the kidneys)
Cuneate Lobe. Me BHAIV, PHWO-
IXMJY OF (Median Aspect of Ceiebml J/emiydtn?,
Cunetix) , I'liYHiouxii, NFUNOUS SYSTEM (Ceir-
In urn, Localisation of Fiinrtitm*, Visital Centre)
Cuneohysterectomy. — The lemoval
of an elliptical (\\edge-shaped, tioiu ciineus, a
wedj»e) pun e of tissue out ul the uteiine \\all (con-
vex side) .it the site ot the angle of fle\ion, and
tht> sii tin ing togethei of the margins of the
wound, the opeiatum is per foi mod by abdomi-
nal section in cases of peisistent and othenuHO
mcmahlc' cases of uteiine ilexion (irtio- or
aute-lle\ion) in oidei to collect the flexion
Cupping1. - \n opeiation in \\hich cup-
ping-glasses aie applied to the skin in older to
dcteinnne an excessive flow of blood to anv pait
theieot (dn/-fU]>j>tm/) , this is done by laiefymn
the an in the cup (by heat 01 by an fiir-pump),,
and the effect may be mci eased by scanfying the
skin (vet-citpjnnf/) and so \\ithdia\\nu; some of
the blood
Cupping of the Optic Disc.—
There is a depression visible about the eentie ot
the optic disc of the eje, and this is known
.is the " physiological ( up " , but under con-
tinuous pi essure (ty in glaucom.i) a "piessure
excavation" 01 pathologK.il degiee oi cupping
takes place, iccognisable on ophthalmoscopic
e\amm<ition Hee (»LAUCOMA (Xi/mptom*, Ki-
<avationof the Optic DIM), RLIINA AND OPTIC
NLHVK (Anatomy)
Cuprum. See COPPEH
Curara. — Cuiara, kno\\n also as Oman,
Wouiara, Womali, Uian, and Cuiaie, is a South
American airow -poison , it is picpaicd fiom
decoctions and extiacts ot vanous plants (an
Aiuni, various species of fitt ychnrss, etc), its
po\\ei fully poisonous effects JUG due to tho
alkaloid (manna (CJ8Hir,N) which it contains r
it paralyses the peiipheral ends of the motor
ncives of the ^voluntary muscles, and has theie-
fore been used in cases of tetanus , it is not
othcial, but there is an Injertio Cutaia1 Hypo-
dfi mica (dose, 1 to 6 m subcutaneously) See
ALKALOIDS (Curanna) , ELECTRICITY (Faiadumi,
Curarised Mwcfes).
Curd Soap. — Sapo Ammalis or Curd
Soap is chiefly stearate ot sodium, and is used
as a basis, being contained m Extiactum Colo-
cynthidis Compositum, Pilula Scaminonn Com-
posita, and Limmentum Potossn lodidi cum
Sapone See PRBSCRHJIN<)
Cure. — Tho word cuie, although generally
signifying a return to health or the means by
which it is accomplished, has also the special
CURE
259
meaning ot a paiticuLu couisu ot medical 01
surgical 01 hxchopathic treatment, thus, there
is the Banting (line foi Obesity (7 v), the Gold
Cure for Alcoholism (a sec ict method), the Giape
Cure tor Habitual Constipation, the Kneipp
Watei Cure (walking barefoot through meadows
in the dewy moining), the Schott due (naus-
culai movements and Nauhcim baths) for Heart
Disease, cte
Curettage, Uterine.
INDICATIONS 239
TECHNIQUE liGO
DAV.ERH AND CUMIIA-IMHC \iiu\i 2GU
See aho Aucmirox (Tteatinrnt, Intomplttt
Aluntton), ATMOKAUSIN, (iiME(X)LOM, DIAGNOSIS
», PKLVIH, I'jhltrN&UM AM) I'KLVIC FlOOH (Ptn-
laj)t,u* Uten, Treatment), UTEKUS, INFLAMMA-
1 IONS OP (Chtonu findonuti itii) , VAPOR MAI ION ,
ZEHIORAUHIH
IT is fifty-six jeaiH since Ilccamier adxised the
scraping of the inside ot the uteius with a sort
ot scoop with subacute edges in cases of metror-
ihagia from " intra-utenne tungosities " , but dis-
couraging «incl ex en fatal lesults followed this
fust use of the cuiette, and it was not till 1863
that Mai ion Sims xentmed to chaiac tense the
operation as a piactue " now iccogmscd as legiti-
mate " Sims' cuiette was a shaiponc, and so
x\as the spoon c uiette ot Simon intioduccd m
1872 , but the blunt mstiument invented by
Thomas, and populaiised in this country by
Munde, by its almost complete safety did a gicat
deal to establish the curette in the U\ om ot the
piofcssinn Its chief use was as a means of
diagnosis Since 1878 the sphcie of usefulness
of the uteiino curette has been enoimously
widened, shaip and blunt and flushing instru-
ments are employed, and the operation of
cuiettage is looked upon as one requiring care
and skill, and not simply as a tnfling diagnostic
method which could be safely earned out on the
consulting-room couch
The INDICATIONS for curettage may be divided
into therapeutic and diagnostic, and of these
the fonuer are nowadays regarded as the more
important, and will be considered first
T/ietaj>euti< t/w —(1) Jfonion harje from the
genital organs is one of the commonest and
most fully established uses of the curette The
bleeding may be from the cervix uteri, or even
from the vaginal walls, as in cases of malignant
disease of these parts, and then the curette acts
only as a palliative, in the great majority of
cases, howevei, the hemorrhage is from the
body of the uterus, and curettage is at any rate
expected to bo curative Uterine corpoieal
haemorrhage may be due to retained products
of conception, as after an incomplete abortion ,
then the cavity may be cleared out with the
index finger, which is, under the circumstances,
the best curette , but if the cervical canal has
closed and the bleeding continues, notwith-
standing the lapse of some days or weeks, then
dilatation and a thoiough cuietting of the m-
tenoi will bo needed, foi decidual remains are
often very firmly fixed, and need not be of
much si/e in older to set up a great amount of
hicmoirhage Again, the ha?moirhage may be
due to chionu non -septic hypei plastic endo-
metritis, and m such cases the removal of the
gieatly thickened endomctnum by the cuiettc
(blunt 01 sharp) with previous dilatation of the
lervix will often give immediately satisfactory
it-suits, especially if the curettage be followed
by a thorough cautciisution ot the uterine m-
teiioi It cannot be said that htemoiihage from
a uteius affected with tibioid turnouts has been
moie than tciJiprT.ii ily checked by curettagc,
ior the mucous mcmbiane under these circum-
stances is not alwa\s hx.poi trophic (it may
indeed bo atiophic), and the congestion may be
seated in the musculai eo.it, w hie h is of course
beyond the reach of the sci.ipmg In the case
of sarcomata and caicmomata ol the body of the
uteius the cuiette is only a palliative means of
treatment, but it has a value as a diagnostic,
and, turthci, it may be used as a preliminary
pioecduie befoie the perfonnanco of vaginal
hjsteiectoiny for these utcime tumouis
(2) tie/) tic and other infected htate* of the
uterus, and even of the Fallopian tubes, have
dm ing recent years been tieated by cuicttago,
but all gynecologists aie not agiccd as to the
value of this indication, and, of coin so, all
infected states aie not equally amenable to
curettage In acute septic endomctiitis, foi
instance, following aboition, or even labour at
the lull term, the curette must bo used only
after consideration, and not as a routine plan of
ticatnicnt; but even under these conditions it
has its uses, especially if intra-uterine douching,
lodoform packing, and the antistreptococcic
serum fail to reduce the temperature (Jreat
eaie must be taken not to perforate the soft
walls of the pucrpeial or post abortum uterus
In chronic infected states in which the uterus is
enlarged and displaced, menstruation disordered,
and puiulent and profuse leucoiihcra in exist-
ence, the curette often gives the best results
I4] ven in cases in which the appendages are in-
fected it has been recommended that the uterus
be curetted m order to drain pus -containing
tubes through it
(3) Dysmenoi rJwea and sterility form yet other
indications for curettage, but it is often difficult
to separate those from the eh ionic infected states
At any rate it is probable ttiat the straightening
of the uterus and the dilatation of the cervical
canal may be as efhcacious as the curettage in
the improvement which undoubtedly sometimes
follows (4) In the induction of abortion for
dangerous conditions m pregnancy, such as m-
coercible vomiting, the curette (preferably the
blunt variety) may be employed, especially when
260
CURETTAGE, UTERINE
it is important to carry out the induction rapidly
and with small loss of blood (5) Curettage
may be used as a jno2>hylcu.ttc and preliminary
procedure when it is intended to operate on the
vaginal walk or cervix, or to do hysterectomy,
m order to prevent the infection of the wounded
surfaces with septic materi.il, etc, from the
uterus
The difu/nottu «??< of the curette consist in
the removal by this means of scrapings ol uterine
mucous mcmbiane and then examination under
the microscope in order to separate conditions of
simple endometritiN from sarcoma and carcinoma,
and even from fibre-myoma of the utei us
THB TEC-HNIQUE — When the condition calling
for curettage permits the fixing of dates before-
hand, the time chosen should be the week aftei
the menstrual period On the day befoic opera-
tion the patient should keep in bed, her urine
should be tested, and some opening medicine
should be guen, to be followed by an enema
next moinmg The \ulva and vagma should be
thoroughly scrubbed out, and the operator and
assistant should take the sime personal pre-
cautions to ensure surgical cleanliness as if a
laparotomy were anticipated The aimament-
arium consists of a curette, which may bo eithci
Martin's sharp cmette (which closely resembles
that recommended by Recamiei), 01 an instru-
ment with a hollow stem, by means of AN Inch a
stream of antiseptic solution can be sent thiough
the uterus (flushing curette) , a vaginal &j>eciilum,
such as Simon's , two or moie strong-toothed vol-
«ellffl with clips , a set of cervical dilatois, such
as Hejrar's, thiee or four uterine sounds 01
I'layfair prolxjs aimed with cotton-wool , a male
•catheter, No 10 , an mtia-utorme douche and a
pair of curved packing forceps , some pledgets
of gauze, and uidoform gauze m strips ior pack-
ing There should be at hand a bottle of iodised
phenol for applying to the interior of the utei us
on the armed sounds, if regaided uecessaiy ,
there must, of course, be an anaesthetic (chloro-
form), and an antiseptic solution (perchlonde of
mercury, 1 m 5000) The patient, having been
amcsthctised, should be placed in the lithotomy
position on a table m a good light. The field
of operation should be protected with sterilised
towels, and the hips should be raised upon a
pad of antiseptic cotton covered by mackintosh
The external genitals and vulva should be again
thoroughly washed and sciubbcd, and the urine
drawn off The speculum is then passed and
held m position exposing cervix and vaginal
vault, and the operator seizes and drags down
the cervix by means of the vol&ellte, one being
attached to the anterior and the other to the
posterior lip If the uterus be fixed by pelvic
adhesions this should not be attempted The
dilatation of the cervical canal is now begun,
unless it is already sufficiently open to allow the
passing of the curette , the Hegar dilators, which
have been carefully sterilised, are now slowly
mtioduced one after another, beginning with
perhaps a No 3 and working up to a No. 13 or
14, and always allowing a minute or two to
elapse between successive ones From fifteen
to twenty or e\eii thirty minutes should be
allowed for this part of the operation Each
dilatoi should be wanned and oiled befoie intro-
duction The cuiettc is now passed into tho
utcius and the walls systematically sciapcd with
it (fust nn tenor, then posterior, and so on), the
sci aping, which is accompanied by a ci caking
("lo en utci in "), being conti oiled by the left
hand placed o\ei the abdomen The contents
of the cuietto should be floated oft into a cup
of cl&iii watei for futuie micioscopic examina-
tion Next, the utei me cavity may be washed
out with an antiseptic solution, and iodised
phenol applied to the inteiior on sounds or
Play fan piobes if the caustic effect be desired
Finally, the uterus and vagina should be packed
with a long stiip of lodoform gauze, a pad of
antiseptic absoibent wool should be placed over
the vulva, and the whole held m position with
a bandage A hypodermic injection of ergotiu
(3gi ) maybe given to aid utei me contractions
The patient is then put back to bed mid kept
quiet The urine may lequue to be dia\ui off,
but it is often passed natiii all} If the cm ettage
has been done for siippurativc conditions, the
packing may need to be frequently changed , if
not, it may be allowed to remain in foi two or
three dajs The patient should be kept m bed
for five days 01 a week, foi lon«ei if the opera-
tion has been performed for giavc conditions,
she ought to icst in bed at the ncvt menstiual
period, as the disthaige. is sometimes evessive
then, and marital relations should not be re-
sumed for eight weeks in oidu to peimit of the
complete lestoration of the ondomctiiiiiu H
has to be borne in mind that curettage docs not
prevent future conception , it has indeed aired
stenhty
The DANGERS of uterine curett.ige, if carried
out with surgical cleanliness, aic not many or
gieat Occasionally perforation of tho utei me
wall has occurred, especially when the operation
has been done in the puerpeiium , then if grave
symptoms, such as luemorihafcc or prolapse ot
intestine, appeal, it may be necessary to per-
form hysterectomy, but in many cases no harm
has lesultcd Sepsis is not a common danger
nowadays when curettage is looked upon as an
operation and not as a diagnostic method to be
done in the consul tmg-ioom or with the patient
in bed Abortion may icsult through want of
diagnosis of pregnancy, therefore it is always
well to inquire into the menstrual history, and
to make a careful bimauual examination before
beginning the cervical dilatation Complete
obliteration of the uterine cavity has m a few
instances followed curettago, possibly on account
of a sort of supenn volution Rupture of puru-
lent collections m the pelvis is a danger which
CUKKTTAGE
CURETTAGE, UTERINE
261
used to be much feaied, and tubal disease and
peiimctritis were formerly regarded as CONTRA-
INDICATIONS to curettago , but the risk has prob-
ably been exaggerated, and it is now held by
some gynecologists to bo good treatment to use
the curette in those very conditions which wore
regarded as contra-iudications Of course undei
those circumstances the alternatives are vaginal
hysterectomy or laparotomy. Pregnancy is a
certain contra-indication, save when it is de&ned
for some good reason to induce abortion
Currents. See PHYHIOLOGI, TIIK Tissue
(Jfff*cA>, Electrical C/mnr/eg)
Curschmann's Spirals. See
ASTHMA (Symptom*, Sputum) , BRONCHI, BUON-
scojural Exnminntton of Sp-utum, Cwvhmnnn's
Curtilage. — In sanitary la\v
is defined as "a courtyard, backside, or piece
of ground lying near to a dwelling-house "
Curvature. See SPINE, SURGICAL AF*EC-
TIONS OF (Later a/ Cwvatute tn «SW«ws),
SIOM^CII, DISEASES or (An<ifoti)i/, Cmvntute)
Curve, tire CAULS, CURVE OF, EMRR\O-
Lorn (Curre\) , («KNEIIAIION, FEMALE ORGANS o*
(Pelvn, Cujve*), LABOUK,
Cut vet)
Cusco's Speculum. ,s
DIAGNOSIS iv (Vm/tnal Specula)
Cusp. — A pointed end, pi ejection, 01 ex
tremity, e tj. of the ciown of a tooth (ThETH,
Anatomy), or of the \alvcs of the heait (1'nvsio- j oigamc radicle
iAXi\, riurui vi ION, I fern t^ Valvrv)
aoid, an oil, etc See ANTHELMINTICS , PAR ASHES
(Gestodei, TtPnui Sohum)
Custard. See INVALID FEEDING (Prepared
Diet during Cotwalescence)
Cut Throat. See NECK, REGION OF (Cut,
Throat), MEDICINE, FORENSIC (Suicide)
Cutaneous Diseases. See DERMA-
rrrih , SKIN , MYIAHIS , etc
Cute. *S'«e CARAT fe, PINTA
Cuticle. — The epideimis 01 scarf skin
See PHYhioiotir, TISSUES (Epithelium, Stratified
Synamow) , SKIV, ANATOMY AND PHYSIOI ocn.
CutlS. — The skin, especially the cormm or
derma , rut it anteiiwi or goose-skin is that state
oi the integument \vhen from emotion or cold
the hair follicles aie elected and form projections
on the buif.iec , <•?/// s 1<ua is a loose condition ot
the skin, dermatolysis , and (utit tcttacea is a
name for iththyon* neonatot um
Cuvier, Duct Of. — In the embr}ro the
cardinal veins (anterior or jugular and postcnoi)
unite to form the duct of Cuvier which carries
the blood to the sinus venosus which opens into
the auricle of the hoiut See EMBRYOLOGY ,
HEART, EMBRYOLOGY
I Cyan- or CyanO-. — In compound \vords
tyan- oi cyano- (from Cr Ki'-ai/os, dark blue)
moans cithci blue in colour 01 else relating to
tho chemical compound cyanogen (C,N2), for
instance, ryitnoni (vide infta) means blueness of
the skin, cyanurm is a blue deposit found
occasionally in the urine, uhile a cyanide is
i a compound of cyanogen \uth a metal or an
Cusparlae Cortex. <fo? aho CAU-
M1NAU\FS, PlI \RMACOI CH11, etc CltSjHIIHI Jllirk
or AwjuKtuiaJiaiJi is the dried baik of Cw*paim
febnfwja, it has a disagieeablo odour and a
bittci aiomatic taste, it contains several alka-
loids (eg cunpaune or angustuime, (^^IO^^P
yalipine, C20H21N03, and cusptu idi lie, C]0H17NO ,),
a bittei principle (anr/o*turin), and an aiomatic
oil , its omual piepaiations aio lnfu*uni Cuvparur
(dose, 1 to 2 fl o/ ), and Liquor CuipatM? Con-
cent) <itut (dose, J to 1 fl dr ) , its action is that
of a stomachic and carminative (like Calumba
Hoot), it is used to make Augustuia Bitters, and
it has boon used as a febriiugo (in S Ameiica,
whence it is obtained)
CUSSO. — Cuwo or kousv) consists of the
dried panicles of an Abyssinian plant of the
order of the Rosacetu (Tiiayera anthelminttca),
and it is occasionally used as an anthelmmtic ,
it contains an active rcsmoid punciple, koussm
,8O10), soluble in alkalies, along with tannic
Cyanate. — A salt of cyanic acid (HCNO),
such as potassium emanate (KCNO), 01 lead
cvanate (rb(CNO),), or ammonium cyanate
(NH4(1NO), which Wohler (in 1828) succeeded in
transforming by evaporation into urea (CONSH4),
an isomoric iorm
Cyanic Acid.— A colourless volatile
j liquid (TICNO), producing a caustic effect, and
I torming salts (cyanatos) with metals
Cyanide. — A compound of cyanogen
(CjNs or Cy) uith a metal or an organic radicle,
ey potassium cyanide (KCN), potassium ferio-
cyanide (K4FeC0Nfi), mercuric (Hg(CN)2) or
silvei cjamdo (AgCN) fife DERMATITIS TRAU-
MATICA ET VENENATA (Social Ki uptions) ,
TOXICOLOGY.
Cyanogen.— A compound radicle (C2N2),
which can be isolated, by heating mercuric
cyanide, as a colourless gas burning with a
peach-blossom coloured flame. See TOXICOLOGY
( Cyn n ot/rn Compound*)
262
CYANOSIS
CyanOSiS.— The morbid condition in
which the skin has a bluish colour, due to im-
perfect aeration of the blood on account of con-
genital malformations of the heart (morbus
cceruleus) or of asphyxia or collapse. See
BRONCHI, BRONCHIAL GLANDS (Enlarged Glands,
Symptom* and Signs); BRONCHI, BRONCHITIS
(Insanity of Cyanosis); HEART, MYOCARDIUM
AND ENDOCARDIUM (Effects of Cardiac Disease) ;
HEART, CONGENITAL MALFORMATIONS OP (Physi-
cal Si(jns); RAYNAUD'S DISEASE; TOXICOLOGY
(Nitro-bcnzene, Aniline).
Cycle. — The period of time during which
certain events occur in a definite sequence ;
usually one cycle is followed by another in which
the same events occur again in the same order.
See HEART, PHYSIOLOGY OF (Cardiac Cycle] ;
MENSTRUATION ; PHYSIOLOO Y, CIRCULATION (Heart,
Cardiac Cycle),
Cyclic Album I nu ria.— A morbid
state of the urine, in which albumen is found,
but only at certain hours of the day. See URINE,
PATHOLOGICAL CHANGES IN (Albuminuria, Signifi-
cance of).
Cycling1. See ANKLE-JOINT, REGION OF,
INJURIES (Sprain, After -Treatment); APPETITE
(Loss of, Treatment).
. — Inflammation of the ciliary
body of the eye. See GLAUCOMA (Causes of
Secondary) ; IRIS AND CILIARY BODIES (Inflam-
matory Conditions, Cyclitis) ; SYPHILIS (Tertiary,
Eye and its Appendages, Cyclitis); TYPHOID
FEVKK (Ocular Complications).
CydOCephalUS. — The teratological
state of the face in which there is a single median
eye, or in which two eyes (separate or fused) lie
in one median orbital cavity ; a nasal proboscis
above (or below) the median eye may or may
not be present.
Cyclone. See METEOROLOGY (Wind*,
Cyclones and Anti-Cyclones).
CydOplegia.— Paralysis of the ciliary
muscle. See EYEBALL, INJURIES OF (Crmtusion,
Cycloplegia) ; IRTS AND CILIARY IJoniE.s (In-
juries, Traumatic Mydriasis).
CyClOpia,. — The single-eyed monstrosity
(synopsia), in which the two orbits and their
contents are more or less completely fused to-
gether in the middle line of the face, so named
after the one-eyed Cyclops (Polyphemus) of
mythology ;< there is usually a nasal proboscis
or tube above the single orbit, and there arc
commonly four eyelids ; the brain is markedly
malformed, the corpus callosum, falx, septum
lucidum, olfactory lobes, and optic nerves being
of ten absent. See CEBOCEPHALUS ; CYCLOCEPHALUS ;
; $f |*i
type tta
CYCLOTIA
263
median double eye with absence or defective
development of the lower jaw and approxima-
tion of the external ears below the defective face ;
cyclops hypo-agnathus (Taruffi). In the accom-
panying illustration the single eye (on the top of
the head) is not shown. See CYGLOPIA ; etc.
CyesiS. — Pregnancy (Or. KI'»/CTI«, pregnancy
or conception) ; pseudocyesis, therefore, is spurious
pregnancy, and cyesiognosis is the diagnosis of
pregnancy.
Cylindroma. A variety of epithelioma,
containing cylindrical hyaline bodies, occurring
most often on the face.
CyllOSOmUS.— A teratological type in
which there is lateral event rat ion in the lower
part of the abdomen with absence or incomplete
development of the lower limb of the same side
(Gr. Ki;AAo<j, crippled, and (nf»/tu, the body).
Gynriene. — One of the benzene series of
hydrocarbons; it is really methyl-isopropyl-
benssene (C10H14) ; and it occurs in several vola-
tile oils (e.g. oleum eucalypti and oleum c.arui).
Cynanche. — Acute inflammation of the
throat or of the neighbouring parts, CM using
difficulty of breathing and of swallowing, some-
times with protrusion of the tongue (Gr. KiW, a,
dog, and u.y\€iv, to strangle) ; there are differ-
ent varieties of it, such as cynanche parotidea
(mumps), cynanche laryngca (croup), cynauche
thyroidea (goitre), cynanche tonsillari.s (<]uinsy).
/See ANGINA, and under the various diseases
(LARYNX, ACUTE INFLAMMATION ; etc.).
Cynanthropfa. — That form of insanity
in which the subject behaves like a dog (barks,
runs, etc.), imagining himself to have been
changed into one.
A
CyniC Spasm.— The contraction of the
facial muscles by which the teeth arc shown (as
in a snarling dog), by the approximation of the
angle of the mouth to the outer canthus of the
eye.
Cynobex Hebetis. - The harking
cfuu'h of puberty, a peculiar convulsive or
-pasmodic. rough occurring mostly in boys
about the age uf puberty. See HYSTERIA ;
SPASM ( Varieties}.
CynocephalUS.— The teratological
type in which the head of the foetus resembles
that, of a dog; it is generally the result of
aneneephalus or exeneephalus.
Cynolyssa.— itabies (//.?>.).
Cynorexia. See BULIMIA.— A vora-
cious appetite ; " hungry as a dog."
CyOtOCia. — Parturition (Gr. KVOS,
ovum, and TOKOS, birth).
CyphosiS. See, KYPHOKIS; SPINE,
SURGICAL AFFECTIONS (Angular Curvature) ;
etc.
Cyprus Fever. See UNDULANT
I-'KVKK; MALTA FKVER.
Cyrtometer. — An instrument for
measuring the curve of any part of the
body (Gr. Kvpros, curved, and /terpov, a
measure), especially of any part, such as
the chest, in which the curve is constantly
varying; the curved tracing obtained is a
cyrtograph. See PHYSIOLOGY, RESPIRATION
(Movements of Ghent}.
Cyst. — A morbid structure, consisting of
a wall or sac and contents of varying nature in a
liquid or semi-solid state ((Jr. fc-ixms, bladder).
See BONK, DISEASES OF (Cysts); BRAIN, CYSTS
AND CYSTIC DEGENERATION ; BRAIN, SURGERY OP
(Trephining, Cyst of the Brain) ; JOINTS,
DISEASES OK (Tumours and Cynts) : KIDNEY, SUR-
GICAL AFFECTIONS OF (Cysts) ; KIDNEY, SURGICAL
AFFECTIONS or1 ( Ih/dnlid Cyste) ; LAUYNX, UKNIGN
GROWTHS OF (Ci/stoiitn) ; LIVEN, DISEASES OF
(C7/.<tfx); M.AMMAUY GLAND, DISEASES OF (Cysts,
(•'•i/nclwti\ .]/nUt/i/c., Serous, Hydatid) ; MAM-
MAUY GLAND, DISEASES OF (Neoplasms, Cysto-
A < /enoHxi) ; MEDIA ST i x u M ( Certain Tumours, Der-
mvi'l, Con;/v/ii('tf, ami Hydatid Cysts); NECK,
REGION OF (('t/st.t <iml Cystic Tumours); OVARIES,
DISEASES OF (Cystic Tumour.*. l>r<><«l Ligament
264
CYST
Cysts, etc), PALATE (Tumours, Detmoids, Cysts),
PANCREAS, DISEASES OF (Cysts), PERITONEUM
(Neiv Growths, Cysts) , PERITONEUM, TUMOURS OF
(Cysts, Dermoids).
CySt- Or CyStO-.— In compound \\ords
cyst- or cyito- generally means relating to the
bladder (unnaiy or gall bladder) 01 to any cyst-
like structure
CyStadenoma.— An adenoma rontain-
ing cysts
Cystalffla.— Pain m the bladder, espe-
cially the cases in which there is no lecogmsahle
lesion *SVe BLADDER, INJURIES AND DISEASFS
(Chionu Cy*tittt>, Dun/now) , HYSTERIA (Dis-
order? of the Utinaiy tiyittm, Jiladdei)
Cystatroptiy.
(uiinary)
Atiophy of the bladder
Cystau chen otomy.— incision of the
neck (Gr c«'\?ji/, the neck) of the 1) ladder (mi
narj)
CyStaUXe.—H) petti ophy of the bladdei
(uiinary), especully thickening ot the walk
(Or aiif*;, enlaigcment) , tysthjpeisaicosis
CyStOCtaSy.— The opeiation bj which
foreign bodies are extracted fiom the 111111.113
bladder \>y foiceps, the pros tat ic uietlna having
been dilated and the inenibi tinous urethra
divided
CySteCtOmy.— Excision ot the bladdn
(gall)
CyStenCephalUS. — The teiatological
type in which the basis ei aim is co\eied by a
sac containing fluid and repiesentmg the hi am
CyStlC.— Cyst-like, 01 bladdei-hke, 01 be-
longing to the uinmiy bladdei or the gall-
bladder *SVr ABDOMEN, INJURIES OK (JlllptUlP
of Cystic Ihat) , NE<-H, REGION OK (Cy\ttc II y
groma) , PROSTA PF ( i LAND ( ( 1t/vtic Di s< a * s) ,
URAPIIUS (C\sric DILATATION ot), etc
CyStlcerCUS BOVlS.— The »cole\ 01
larval stage of the tapo\toim, Ttrnia ni&lio-
canellata bee PARASITES (Cestorks, Ttnwi
tiaginata).
Cystlcercus Cellulosse. — The
scolex or larval stage of the common tapeMoim,
T(fnia solium See HIDATID DISEASE, Oitiui1,
DISEASES (Paiasitic Gy\ti) , PARASITES (6Vs^/ci,
Tivnia Sokum) , TONOUE (Cytts) , TUMOURS OH
THE SKIN (Cyvticercus Cellulosrr Cntu>), VITREOUS
HUMOUR, DISEASES (Pai asite*)
Cystlcercus Tenulcollls. — The
laival stage of TCPUM marginata *SVe PARA-
SITES (Ce^twlen, T(rnm Matyinata)
CySt In.— A iaio deposit in wine (cystni-
iirin), consisting ot hexagonal cijstals, some-
times foimmg calculi , it is the disulphide of
anudopropioniG acid (0<HrNOJSS) , it is not
soluble in \vaim water 01 dilute acetic acid, but
is freely so in ammonia , it gives to the mine an
odoui ot bwcct bnai which soon changes to a
disagioeable smell *SW PH\SIOIX)O^, EXCRKIION
(Uiine, ftuljthm -ctmlninmq Bodies) , URINE,
PATHOI CMHC VL (/IIANUES \t<(Ci/stinwi<i,tie(hinent\,
Ci/*ttn), I!N< o^s< IOUSN^S (Anto-lntfu,un,t'iont>,
Cybtinw 10)
Cystitis- Hw BLADDER, DISEASES oi< (In-
Jlammntwm, A<nte and Chronic), BLADDER, IN-
JURIES AND DISEASES OF (GVf/ru/fft Veficte, Din-
r/izotM) , BLADDER, TUMOURS 01- (fiymjitouu) t KID-
NEY, SuRoir \LAi I'EcnoNsOF (Pyehtis, Efiolor/y),
PAR MA MIS (tiubtuute (Jointnntd Dcyenet ntitm, of
the Coid, tiynyitontt*) , PFLMS, PERINEUM AND
PELMC PrxxwfG'ystof/*, Complication), RECTUM,
DISEASES OF (Cyvtitt* a ('auw of Rental »SV»t/>-
foms) , Sl'KHMA10RRII(KA(GV/MS^«f), SMUN(.OM\E1 IA
(G'rtwv of Death), Tvnioii) KE\ER (Coinplua-
fions, Cyititiv), (TRAfiius (/'Wti/f/, GVms^s ot) ,
\ KHHUA, DISEASES or ((fonnn/uta, Cnni/tlim-
tion\), riiiNJ«, BACIERFV iv (Cystitis)
Cystocele. X<'<' Bi ADDER, IMURIPS AND
DISEASES OF (MtilpnvtHwi, llnntn ot Ci/*tore/e) ,
HFRMA (ll&ma of tipenal Fittm Jttaddn),
LABOUR, INJURIFS TO THE (JEXERAIHE OROAISS
(Injwie* to the /'mnewm, ftnulh) , PELMS,
PFRINEUM AND PI-LMC FIOOR ((h/\lwvlt) , PRK,-
NA\C\, Al'TE< HONS AM) CoMl'LK'AllONS ( Vewal
, UIERUS, Disi'LArEMi*MsoF (l*to-
of the Uteiuv,
Cystodynia.
Cystoenterocele. — A h<>ima con
tdinmg both bladdei and intestine, \\hen tlu>
omentum 11 also included, it is teimud a
<.i/\tot>nteroeinplo<ele , >vhen the omentum and the
bladdei aie the contents, it is named cj^toepi-
plowle
CyStOllthiaslS.->Stoncoi gia\el in the
bladdei.
Cy Stcma* A (}bticgro\\th, ft/ an o\a-
nan cystoma
CyStOptOSlS.— Piojection of thc^ \csic.il
miu'oiiis membiane fiom the uietlna due to le-
la\ation of the same
CystOpyelltlS. — Inflammation of the
bladder and ot the peh is of the kidney fiee KID-
NE\, SURGICAL AVIFGI IONS OF (/tymiei, Retitlti)
CystorrhexIS.— Kupture of the unnaiy
bladdei (e <j in injuiies or in ietio\ersion of the
giaMd uteius).
CystOSChlSlS.— H:\tio\eisioii ot the uii-
nary bladder or eitopia \esicie
CystOSCOpe, the. ^ee also BLADDER,
INJURIES AND DISEASES OF (Turnouts, Cyvtowopic
Examination), (i\NKroioG\, DIAGNOSIS ix(Cysto-
CYSTOSCOPE, THE
265
*cnpy) , HAIMATURIA (Differential Diaynow,
Cyvto8co}w) — To examine the interior of the
bladder visually without a tutting operation is
no new idea In 1805 Jioxzmi of Frankfurt
devised and exhibited an instrument foi tlus
purpose, which, howe\er, \\as iound to he quite
inadequate because of insufficient illumination
Desinorcau, in 1854, introduced a cjstoscope,
which, in 1865, \vas fuither elaborated by Di
Tiuisoof Dublin These and all other msttu-
inents pnoi to 1877 may be eoiibidcicd the hist
stage of the cystoscope, as the light foi illumma-
tion was extenuil to the bladdci, but in that
yeai Dr Max Nitzc of Berlin introduced the
platinum loop instniment with the light intoi n il,
which, although it had rations objections, and
\\as soon condemned because of its eumlnous
size and defectn e light, initiated the sec ond stage
of the cystoscope 01 hglit mtet nal idea, and led
up to the more perfect instiument of to-day
Not until 1887, ho\ve\ei, did surgeons find an
n strument xxoithy of a place in then armamcn-
tanum, \\hen, for the hist time, the "incandes-
cent lamp" <ystos<ope x\as introduced This
instiument has been \ariously modified, but the
Loiter cystoscope, aftei the model of Mi Hurij
Fen wick, selves excellently foi thoiough exami-
nation of the bl.uldei
The Tn^ttinnent — Two foi ms of the cystoscopc
— the nntftioi MH\ po\tetu/i-- an* in use, but in
practice the foimci is alone ne< essary It re-
sembles a sound in shape, and consists of the
beak, the shaft, and the o< ulai poition The
beak is hollow, contains the lamp used foi illumi-
nation, and has a \\ mdo\\ thiough \\hith the light
is emitted Funii the lamp two insulated xures
pass along the mteiioi oi the shaft to the o< ular
poition, where they .uc connected with the
electrodes of a batten, the soiiue of elect to-
motive force foi light The shaft is hollow .mil
contains a telescope At the junction of the
shaft and beak, in line with the wmdou in the
beak, theie is a prism \\hic h refiacts the rays of
light from the objei t illuminated on to the end
of the telescope, and thcicfore into line \\ith the
obseiver's eye, so th.it the objec t is brought into
view On the run of the oculai poition, upon
the same aspect as the window and prism, thcie
is a knob which indie ates then position, so that
as the mstiumont i,s mo\ed to and fro, 01 tinned
round within the bladdci, we can deteimme the
pait of the hladdei Mall which we examine
When using the instiument it is focussed lij
withdrawing it fiom, oi appioaching it to, the
object under examination until the best defini-
tion is got It is necessaiy to lemember that
the image is imerted With the antenor cysto-
scope the whole smface of the bladder can be
been, but natuially the most difficult poition to
bung into view is that immediately around the
uicthtal opening A suitable battery, provided
\\ ith a rheostat, is that figured in Schall's cata-
logue No 1192
To 11 *e f/te CyttvwojK — The most caieful
aseptic precautions ate required, just as in the
use of other bladder instrumentation The
cj Bioscope cannot be boiled without injuiy, and
must theiefoie be purified b^ steeping it for a
tune in raihohc acid or l^sol lotion The other
usii.il precautionary measures to axoid ngors
must also be adopted The pain during exami-
nation is no gieatei than that caused by sound-
ing, and it is onh in exceptional c ases that
anesthesia is icquimi, but an .anesthetic may
be exhibited in nei \ons patients or in those with
scnsitne bladdeis In the female, from motives
of dehcaiy, an riiursthclic may be ncccssaiy
In addition to these general measmes theie aie
thiee essentials for examination —
1 The uiethi.i must be of sufficient cabbie
to easily admit tlw instiument
2 rl he bladdei must be capable of holding at
least six ounces of fluid
ii The fluid in the hladdei must bo tians-
paicMit
Meth'nl <>t KraHHUfttton — The1 mine is chawn
off with, by pieteieuce, a led iul)ber catheter
If it be cleat — no blood oi pus -Itom 6 to 12
ounces of waim aseptic solution aie injected,
but if need be the bladdei is hist washed out
that the injected fluid may lemain transpirent
This should be done as gently as possible to
a\oid h.emotihagc, which might tapully cause
the fluid to be colouied, so that the examination
\\ould be difficult, Although it is \eiy tarely
impossible from this cause1 The cytoscope is
now mtioduced, the cncuit being fjpfn, and cat e
taken that the beak is completely within the
bladdei befoie it is closed The circuit having
been ifowf, the obsei\ei's e\e is applied to the
oculai portion, and an endeaxoiu made to detect
an an bubble, which is almost ccitamly pieseut
at the highest point of the fluid This is seen .is
a shimmcimg globule, and indicates the position
of the instiument -gives, so to speak, a land-
maik f loui winch we can proceed methodically
to examine the1 whole bladdei wall The
noimal bladdei \vall has a pale, pinkish-white
colour, with small but distinct blood-\ essels
laimfjing on the suttace The pallor varies
in degiee piopoitionately to the distension
Bladders \aiy in their appeal am e, and it is
only aftei sevei.il have been examined that the
obseixct can sa> whethei a depaitutc from the
usual appoatante is» consistent \\ith health or
not Diu ing the examination the* l>cak of the
iiiHttument must not rest continuously on the
x\all, as it may become hot and do harm , but
this is not apt to occut if otdmary care bo
taken If an abnormality be seen it must be
closely examined to deteimme its exact signifi-
cance A ptojection is moie readil^seen than
a supeificial lesion Diffetent meridians aie
examined by adxancmg and withdrawing the
instrument, but in particular the margin of the
urethinl ojtennu/ , necl of hhvltlM , and tiujone
266
CYSTOSCOPE, THE
are examined The neck of the bladder is
congested in appearance and prominent, but
normally smooth in its outlines The nreteral
openings are at each end of the base ot the
tngonc, with, it m.iy be, an intci-uicteral b.u
They may in some instances be readily seen,
but in othcis require to be closely looked for by
judging the distance and proper angle horn the
lire t In al orifice The openings die uoinially
transverse or oblique slits, and may not be
detected until the margins aie separated by
unne coming through thorn It is necessary,
therefore, to steadily watch lor a minute or two
the area where we expect to find the opening,
so that as the urine is ejected the orifice is seen
If the in me be mixed \vith blood or pus from
the kidney its ejection is mote icadily onset \cd
Bright blood is readily seen (v Case 1, in/m)
If the prostate be much enlarged the beak of
the cystoscope must be considerably depressed
to bring the tngone into view When the
examination is completed the circuit is opened
and the instrument withdiawn It is important
to introduce and withdiaw the cystoscope with
the cncuit o/)cw, as otheiwi«c the beak, not
Ixiing smioundcd by water, becomes hot, and
may bum the uiethra The lustiument should
not be kept for any tune in the an with the
circuit closed, as by fusion of the connections it
may be injured
ValueofCi/^tosrojtt/ In obscure geruto-ui marj
conditions, tx>th as a diagnostic and pioujnostn
agent, the cystoscope is valuable. It ma> enable
the surgeon to say definitely that the bladdei is
01 is not the source of hicmonhage, the oiigm
of which cannot be otherwise deteimmcd That
is equivalent to deciding in some cases whothei
the bladder is to be opened or a nephrotomy
performed Fuither, even if the bladder be the
seat of a tumour, cystoscopy may show whethei
it is suitable or not foi remo\al Whcrevei
there is doubt as logaids the site 01 nature of
disease causing ha-matmia or pyuna, or when
other means ha\e failed to gne .in .uciuatu
diagnosis, cystoscopy should be used Theie aie
two consideiationu, however, of much nnpoit-
ance, which should mvaiiably be borne in
mind — /''//«£, cystoscopy, just as all nistiu-
mentation, should as a rule be avoided in vesieal
tubeiculous disease , and, wcontf, in patients
who are senously ill, 01 in whom instrumenta-
tion is apt to be followed by aggravation of
symptoms, whatevei the reason, operation if
needed should immediately follow the examina-
tion In those cases of \csical tuberculosis,
where the bladder is much inflamed or con-
tracted, cy&toscopy should never be icsoitcd to,
as in these harm is frequently done , simply, it
mav be, «l>y ovei - distension of an inflamed
bladdei , and the method is biought into
disiepute When, however, there is no obvious
tubeiculous disease of the prostate, and the
bladder is of good capacity, if theie be doubt
regarding the source of tubercle bacilli or pus,
cystoscopy IB valuable to determine whether the
kidney is diseased and the bladder healthy
Ncphrectomy in primary tuberculous disease of
the kidney may be curative, and the decision to
pei form the operation may depend upon cysto-
scopic examination showing absence of disease
in the bladder This aspect of the subject can
best be appreciated by the consideration of
illustrative cases, of which the following may
be considered fairly typical —
Caw 1 — Mr .1 I) , .ot 47, complained of
pain in the leit side and blood in the urine.
There was no other symptom, and examination
discovered no disease in either the kidney 01
prostate Cystoscopic examination show cd blood
coming fiom the left uietcral onfice. Nephio-
tomy was performed, but it was only upon cut-
ting into the kidney that a tumour (sarcoma)
was found and nephrectomy earned out For
onejeurtho patient lemamed in good health,
but then a swelling appeared at the seat of the
incision, ami death icsulted one and a half
yeais .if lei opeiation
CW 2 — M S (male), .ut 60 Hwnatiuia
only symptom (Jjstoscopy showed a peduncu-
latcd villous tumoiii on the right infeiioi aspect
of the bladder about one inch above the light
meteral oiihoe The tumoui was removed by
suprapubic cystotomy The patient made a
good recoveiy, and theie was no sign of lecur-
lence for thiee yeaiw Now, foui years from
date of opeiation, tho patient sufteis from
hicmatum, and a laige mass can be palpated in
i elation to the bladder
Case 3 — Miss D , vt 125 , chief complaint,
frequency of rmctuiition The nrmc contains a
f 'on sidci able quantity of pus Pain in tho right
loin has been present ofl and on foi foui ycais,
and on palpation the kidney is felt to be
enlaiged ( tystoscopic examination showed a
noimal bladdei No pus wTas seen coming fiom
eithci ureteial orifice Nephrectomy of the
light kidney was carried out The kidney
contained laigc \omico) filled moie or less with
caseous uiatenal
CUM 4 —.1 S (male), set 50, had symptoms
of stone in the bladdei, but sounding failed to
detect one Oystoscopy showed a small stone
behind a treely mo\able pedunculated middle
lobe of the piostate An attempt to crush the
stone failed as it could not be giaspcd, and
suprapubic cystotomy was had recourse to
This case illustiates that, even when no deep
post-pi os tntic pouch is piesent, a stone may be
missed by the sound That cystoscopy is of
value in cases of post-pi ostatic pouch for the
detection of calculi is undoubted, but tho
examination and operation should, if possible,
| be earned out at the same time In such cases
castration is contia-mdicated, as the stone or
I stories must bo icmovcd to get rid of the
I symptoms
CYSTOSCOPE, THE
267
Many cases, diffcimg from the above, might
be quoted to emphasise the importance of cysto-
scopy, if 8p«icc permitted, but those related will
serve to show that assistance in diagnosis may
be got by its use in (a) tumours, and (ft) calculi
of the bladdei, and in difteient affuctioim of tlu>
kidney To detect the presence .ind nature of
foreign bodies the instiument is also valuable
From the point of vic\\ of piognosis valuable
aid IH also got Thus in turnout of the bladdei,
if a patient have little bleeding and no pain or
frequency of micturition, but suffus from an
irremo\able tumour, i \stotomy should be !
avoulccl -is a rule Rest to the bl.iddoi by I
cystotomy may diminish the lapidity of the i
giowth of the tumour, but it may, on the olhei I
hand, permit an intunsic ginwth to become I
extiinsit, so that eventually much gieatci dis-
comfoit and a more rapidly fatal icsult ensues
Oystoscopy, b\ showing the extent and attach-
ments of the turnout, may prevent an opeiation
which would be huitful to the patient, while,
on the other hand, it may enable the suigcon
name strongly to advocate operation, the
diagnosis being ceitam and the hope of cine
probable The latter point is sho\\n in case "2
quoted above, while the following case illustiates
the formei —
f/rtsp i — Mi H, jet 58, three months ago,
foi the first time, had causeless hiTm.ituii.i
which lasted foi a few days JIc had a seiond
attack ten weeks later, and at the piesent time
suffers fiom a thiidatt.uk Theie is no othei
symptoms, <uid extetnal examination is uegatnc
The uime contains manv large multi-nucleated
cells Piostate not enlaiged on c \amin itiou
j»er rectum Cystoseopic ex.innnation showed .1
tumour attached to the piostate From its
extent and position I believed it to be in-
operable, and advised no opeiation
To decide whether a tumour is opciahle 01
not is fai from easy, and in some cases mi
possible*, but in othei casei theie is not much
difficulty H in doubt I think the patient
should ha\e a c>stotomy The cystoscopn
examination must be xeiy thoiough, and should
pieferably be earned out with ditteient degices
of distension of the bladdei A tnuioui in an
imperfec tly distended bladdei may appe.ir .is a
mass, while if tlu* bladder be inoie fully dis-
tended the mowth may be seen to be made up
of seveial sepaiate masses affecting a much
laiger aiea of the MSCUS I have seen this in
two eases lecently, in one of which cystotoim
showed the disease w.is mopeiablc, while fiom
cystoscopv T believed the disease could be
eradicated
The subject of cystoscopy has in the List ten
years been much widened by the introduction
of apparatus to treat conditions pel urethram,
or to cathetcrise the ureteis Both of these pro-
cedures I believe to be of little piactical import-
ance in the male, and sometimes, indeed, dis-
tmctly mjmious. In the female, however, the
method introduced by Or Kelly, of Baltimore,
is more valuable , although shoit of metcial
cathetensation, equallv good lesults can in the
majority of cases be got by the anterior intcinal
light cystoscope without the* disadvantage of
urethtal dilatation incident to the use of Kelly's
cystoscope Examination by- 1 )r Kelly's instiu-
mcnt is simple, and uieteral cathctensation
with it can be rapidly executed A complete
account of the instiuments required for examina-
tion and the tec hmqiie is contained in Kelly's
wotk Operative (jyneco/oyy The fundamental
pnnciples of examination aie —
1 The introduction of a simple cylmdiical
spei iilum
2 The atmospheric distension of the bladder
by postuie
3 The illumination and inspection of the
hladdci by a dnect light
The instruments icqmicd aie A stiong light,
ahead inn tor, \csical spc'cula with obtmators,
a urethral calibiator and dilatoi, an cvacuator
foi lemoMiig mine, and a uictcial searcher
Local anesthesia may sufhce, and undue
dilatation of the urethia is unncccssaiy
CyStOtOmy. The operation of o])enmg
into the urinary bladdei (for the removal of a
calculus 01 tumour), either by the pcimeal
route (median, latetal, 01 fnfateia/), by the
abdominal (wpiajnilttc), by the icctal, or by
the vaginal loute
CytiSine.— An alkaloid (rioH]4N,0), also
named ttleiute, found in labuinum seeds \Cyti*ub
/abut nuin), and acting as a poison
CytO~a — In compound wotds tyto- ((ii
M'TOS, a i ell 01 pot) mcMiis i elating to a cell
(1i/toMa*t, foi instance, is the cell nucleus,
cy/fWf is <i cell without a nucleus, cytoiJftrH'wi
is c ell-di\ ision , <ytoiicnm\ is cell-fotmation ,
u/lolw/y is the science of cells, ( ytontitonui is
the leticuluni of the piotoplasm of cells, cyto-
jttavn is the ])iotoplasm of the cell as dis-
tinguished fiom that ot the nu< lens (fat i/oplaxm}t
ci/to~oa aie pniasitcs of cells (e </ psoiospeims,
such as coccidia)
Cytodi agnOSia. — One of the most
tecent ad \ances in clinical pathology consists in
the histologieal examination of \anous fluids
dcnved fiom the patient, wheiebv then cell
content may be qualitatively and quantitatively
estimated Coitaiii sccietions w hie h have been
altered by disease, and inflammatory and passive
evudatcs, ate found to contain ccllnl.ii elements
which vary with the cause of the disease process
and with the stage at which this has arnved
It has, of couisc, long been the cu.Aom of care-
ful obseiveis to scaieh vatious secictious and
exudates foi histological evidences of now giowth
where the presence of this has been suspected
In pathological urines, too, the vanous cellular
268
CYTODIAGNOSIS
elements of the deposit have long been examined
critically for purposes of diagnosis, and the
localisation of lesions of the niinaiy ti.ut has
been assisted by recognition of the kinds ot
epithelial cell picsent, togethei with its icaction
to certain dyes, notably ahzaim blue Again,
the diameter of the cells pie so nt in the sputum
has been microscopically investigated, with
results bearing upon the nature and situation
of pulmonary lesions the piesenco ot huge
numbois of cosmophilo lent oc-ytcs in asthmatic
sputum may be instanced The contents of
the blebs in ceitain bull OILS skin eruptions have
been similai ly dealt w ith hci e also the existence
of eosmophifes m lelatively lai»o numbcis in
cases oi ti UP pemphigus has been noted Lastl) ,
most pathologists luve iceogmsed the advisa-
bility ot making a cytolonic.il as well as a
hacteiiological examination of pus obtained
from an} somce All these aie instances of
eytodiagnoMs Hut the method has taken <i
ne\\ departuie during the past few yeais,
and vanoiih inflammatoiy exudates have been
.systematic. illy examined with a view to diflei-
entiating, by means oi then cell content, the
causes of the disease It is to this investigation
particulail} that the teim i}todugnosis is now
applied
Intl
In this field the cbief \\ork h.is been done by
the Ficnth school ot clinical pathologists, led
by Widal, Sicard, and Ita^aud These obseiveis
have obtained results \vhich justity them in
deducing certain formula) ot considetablo dia-
gnostic and piognostic value These foimulo)
aie re( civing dail) confirmation and qualification
by other m \esti <> a tois, me hiding seveial Knghsh
nncioscopi.sts The technique ot the method of
investigation is exceedingly simple The fluid
to bo examined is collected, films aio made
either directly 01 aftei centi legalisation — de-
pending upon the iichness of the material in
cells and w bethel a quantitative examination is,
or is not, needed, — and theno hlms are examined
fiesh and aftei appiopnate stunning If the
fluid clots readily, as in the ease of moht pleuial
effusions of inflammatory oiigin, the clot is
bi ok en up pnor to examination The \arious
cells piesent aie then noted, and a differential
count is madeattei the mannei of a white blood
cell count The cells met with aie of foui
types Three of these are identical with the
commonest cells picscnt in blood — the red hlwid
corpuscle, the polymorphous leucocyte, and the
lymphocyte The fouith cell is the cndothebal
plate derived fiom the lining membrane of the
particul.it caMty whence the fluid has been
obtained Consideration of the significance
of hamioirhagic effusions lies outside the SCOJM?
of this articto The endothehal cell varies in its
individual characteis accoidmg to the situation
investigated, but also, and to a larger extent,
accoidmg to the natuie of the pathological
process present Thus it is smaller and shows
signs oi gieatei actnity in fluids which tesult
fiom inflammations, especially \\hen acute, than
in those which result horn passive exudations
(trausudations) Hut it is to the i elation in
numbers existing between the two foims ot leuco-
c) tes that attention lias been specially directed
In the case of planed efluvonv, and in the
case ot fluid lemoved fiom the mcnttHje* by
lumbai punctilio — the two investigations wheie
the method pio\es to be most profitable — the
following ioimula has been sufficient!} estab-
lished A hijfh lymphocyte count dun in/ the eatly
btayi"* of nn inflammatory pio<e\)> uu/nates that
t/if iviiisf ** a tuhenulou* lufuttou, a hujh poly-
woi photic count tJurnnj the saute \ttufc* tnihcahi
that the caune <s an iHfution by tonic "pyoyaiH "
ot ifam s//* — sti <pto< or i if *, ^tajdiy/oion us, J)M?H'HIO~
ioccuttmenint/ococ< *n, (/o not <x<u\y colon oattlfm, et<
The (|uahhcation as to the stage ot the disease
is neccissaiy, because it has lately been shown
that duiing the stage ot convalescence horn
"septic" inicctions, 01 attei these infections
have become chronic, the polymoiphous cells
piesent in the exudate may gi\e place to Ijmpho-
cjtes It follows, theiefoie, that a change m
uatuio ot the cells iiom the polxmoiphous
\anety to the l}mphocyte indicates a good
piognosis so tar as the stage of infection is
conceined This change is not mfiequentl}
seen when tytodiagnostic observations arc made
incases of mcmngo< oct al meningitis, in which
ieu>\eiy, at least horn the infective stage, is
not uncommon With regaid to the actual
percentage of the dominant cell piusent no
definite statement can be made, the figuics,
howexei, are usually sufficiently pionounced in
the one dnection to le.ivu no dithculty in apply-
ing the foimula — 75 pei cent, inoie oi less, is.
41 figure veiy commonly obtained The figure
may be much higher the wntoi has counted
a fust 100 cells in the etlusion fiom a case ot
prnuaiy tuberculous plcuim, without coming
acios.s a single polymoiphous cell The occui
lence of a pjogenic infection together with
a tubeiculous infection shows itself by the
presence ot a higher polymorphous count than
in a tuberculous infection alone Indeed, in
actual pi act ice, the tubeiculous part of the
disease in these cases is not suggested by the
c} todiagnostic method Thus, plcural effusions
O(c m ung in the course of pulmonary phthisis
obey the " septic " part of the formula, as also
does a teimmal strcptococcal meningitis in the
course of a tuberculous meningitis
In the case of awitic Jlvtd* the foimula is
by no means so trustworthy, however, the
absence of microbic infection may be infericd
from the presence of passive endothehal cells and
the comparative absence of polymorphous cells
and lymphoc}tes In the case of fluid from
inflamed jomtt thoie is as yet no sufficient
body of evidence at hand to wan ant any con-
clusions
CYTODIAGNOSLS
2G9
It will be noticed that the foimula given
above deals only \\ith f/ualifatn>e results of
cell counts Some impoitant indications follow
the <ju(intit<itive examination of eeitam fluids
with legard to their cell content, and this is
paitieularly so \\ith the eeicbio-spinal fluid
Noimal ceiebio-spmal fluid is fice iioin cells,
or contains an occasional lymphocyte onlj A
condition of 1} mphoc^ tosis exists in ceitam
diseases of the ccntial nervous s\stc'm, and
appeals to be piopoitional to the degicc of
mcmngeal imolvemcnt picsent Thus, a slight
lymphocytosis is found to occui in tabes doisalis
and in insulai sclciosis , a somewhat higher cell
count IH present in geneial paialysis of the
insane, in ceiebral syphilis, and in the case of
cerebifd tumours involving the memn<res It
may re.whly be seen that these facts —always to
be taken in connection \\ith the more immcdi-
titcly flmic.il aspects oi the case pi ovule con-
sideiahle assistance in chflcienfial diagnosis oi
neivous diseases, and foim an additional le.ison,
it this A\eie necessaiy, foi the moie extended
use of luinbai puncture as a means of clinical
examination in obsune discuses of the nei\ous
system It need scaicely be pointed out th.it
the < ytcxliagnostic method m<iy yield \aluable
mioimation in deciding between oi^anic and
functional neivous diseases
— Bodies causing dissolution
of cells
Cytoryctes Variolas.
like bodies found by Ouaimeii in the
. — Pioto/oou-
like bodies found by Ouaimeii in the skin lesions
of smallpox , they maj be the cause of the dis-
ease , they are found also in vaccinia (Cyt<ny<ti*
CytOtOXineS. - • Toisons pnxluccd by
cells and capable of destioying cells
CytOZOa. Cell-parasites, sporozoa, such
as the Codidutm ovtfonne found inside the
epithelial cells AN Inch line the bile ducts of the
labbit's hvei ftt PSOUOSPEKMIASIS
DabOia. — A poisonous snake, one of the
Vipeiidju (oi tine vipers) "Kiihsel's vipoi " of
India and Ceylon See SVAKL - HIILN AM>
Poisoxous FISHES
Dacry-. — In compound \\oids <t(utt/-
(fioiu Ui 8uK/r)vor, a tear) gencially means
i elating to the laciymal gland oi duct or
(raicly) to the phenomenon of weeping, thus
dact yademtis IH inflammation of the laciyinal
gland, dacryadenftli/Hi is pain in the lacrymal
gland, and d(uryqelom.* (Gr faiicpvov, a tcai,
and ycAuw, I laugh) is a form of insanity chai-
actensed by alternate fits of excessive weeping
and laughing Vide infta
DacryoadenitiS.— Inflammation of the
laciymal gland, also spelled daci yadentti*
Dacryoblenorrhoea.
(mucous) taking place fiom the laciymal sac
and ducts
— Inflammation of the
lacrymal sac oi gland, catairfial or suppurative
Xee LAc-imiu, API-ARGILS, DISEASES 01 ((Hand,
Inflammation) The ocdiircnce ot .1 mucous
disdi.uge fiorn the sac is termed diuryocysto-
, piol«i])sc» of the sac IH dat tt/otf/sto-
\\hik- a hernia of it is i
Dacryolith. — A calculus 01 chalky con
action blocking a duct of the laciymal gland,
oi i canahculus, 01 the- sic .S'w L \rit\MAi
AiTAitAii s, DISK \si-s oi (J)iwwi of Gland)
.- Obsti action of one or both
of the punt ta lachrymaba, pteventing the
passage of teais into the laciymal sac
Dacryon. — The jxnnt ,it the side of the
loot of the nose \\hcie the fiontal, the lacrymal
bone, and the asc ending piocess of the supenor
maxilla meet, used .IH a landmark in ciamo-
metiy
Dacryops. A r}st-hke distension of a
duct of the laciymal gland, also a "\\ateiy
e^e" Xte LAC in MA i, A pp \u\i us, DISKVSES o*
(Gland, />/stas<A , (Jy^tu. (jitnctli)
DacryOSOlenitlS.— Inflammation of the
laci>mal cluc't (fiom (Ji Sdkpiov, a tear, and
(r<i>A//i', a channel)
DacryOSyrinX.— A fistula lachiymahs
((ir a-tpiyg, a pipe)
Dactyl it is. — Inflammation of the fingeis
01 toes (Ur fiuKTrAos, a nnjic^ oi toe), especially
that foim muhichthcic is maiked enlaigemcnt
of the digits of a syphilitic (gummatous) natuie
(dtl(tl//ltl\ \yjt/H?ttiC(l) tfie llc)NE, DlSEASEH OF
(Tulu i culout DIWIW m t/u Inlirtot of Bone*,
Tulx 1 1 n Ion s Dai tyh ti s) , lie »\ F, 1 > IHEASRS o»
(Si/jihihltc n<ntyhti&) , FIVC.EUS (Detain* ot
Jtone<> and Joints, DoLtyhtis) , HAND (]ion<*>,
toutylitn) , SYPHILIS (Tettuny, hones nnd
/tnnt\)
Dacty lOlySiS. Spontaneous amputation
of the fingers 01 toes met \\ith at bnth, and
ascribed by some to the piessuie ot the umbili-
cal coid 01 of bands of ammon 01 oi lymph, and
by otheis to a cutaneous lesion (\i/ proliferation
and do>\ngio\\th of the surface epithelium) , it
is m connection with the List-named theory that
the teim ejnthclial dtnty/o/yw\ has been grvcn
(Men/el) , perhaps this congenital s^ite is allied
to the disease called ainhum (7 v \o\ i p 76)
Dactylotheca.— A fmgci-cot, a pro-
tective covering used in ceitaiu examinations
and manipulations
270
D^SMONOMANIA
Da»monomania.— A form of insanity
in which the patient (usually suflfenng from
religious melancholia) imagines himself the
subject of possession by den ils , dcmonomama
Dairies, tic? MILK (Industrial, Hytjittu
of the Dairy) , Cow-SiiEiw — Both in English and
Scots sanitary law d.uiy means " any farm, farm
house, cow-shed, milk-store, milk-shop, or other
place from which milk is supplied, or in %\ Inch
milk is kept for put poses of salt* "
Dalby's Carminative.— A soothing
preparation containing about two and a halt
minims of laudanum to the fluid ounce «Se*e
ToxicoixXf\ (Alkaloid* and Vegetable Potion*,
Opium and Motphine)
Daltonism. — Colour-blindness, so called
because John JXilton, chemist, studied and
cai chilly described the condition of red-blindness
or anerythropsu in himself See CoLoim VISION
(Golow-Jihiulntk* tn Achiomtitojwa)
.— A Mexican plant (Tutneia
aphiodtwaca [?] or Ihi/ifovni veneta [?]), legnirled
as possessing aphiodisuc qualities and an being
a nerve tonic
Damp. Met- SroMtrH AND DUODENUM,
DISEASES OF (General Etioloyy, Cdd and Damj>)
Dance, St. VltUS'S. See CHOUEA
Dancer's Cramp.— Ciamp ot the calf
ninsclcs, especially oecuriing in ballet-dam ers
Dancing Mania.— A form of epidemic
mama (met with in the Middle Ages, often in
association with religions excitement) in which
dancing and gesticulating weio piominent
symptoms, St Guy's or St John's dance,
pandemic chorea , choromama
Dandelion. See TARAXACI RADIX
Dan d riff or Dandruff.— Scurf or
dead scaif-skin still adhering to the skin or to
hair on the skin , pitynosis See ECZEMA ( My-
cosiform,, Pitynasis Capitis)
Dandy Fever. See DKVGUE
Daneverd. Xee UALNKOLUO\ (Sweden)
DanfferOUS Trades. See ANTHRAX ,
TOXICOLOGY , TRADES, DANGEROUS
Daphne Mezereum.— The root of
this plant yields the me/oroum of the United
States Pharmacopoeia, cases of poisoning from
eating the berries have occurred, the bark is
ofhcial in the British Pharmacopoeia, and con-
tains daphnin, a crystalline glucoside (C15H16Ofl),
which boiled with dilute acids gives daphnetm
(C9Htf04) and glucose See MBZKREI COBTKX.
Darter's Disease.— A rare chronic
disease ot the skin, characterised by the occui-
icnce of papules in regions of the body well
supplied with sebaceous and sudoriparous glands
(ey the axillae and the groins), by the later
formation of greyish-brown 01 black crusts, and
by the still latei de\elopmeut of inflammatory
nodules and ulceis , the disease shows some 10-
semblancc to lichen planus , it is pi ac tic-ally an
incuiable malady, but good can be done by the
use of antiseptic remedies and thorough cleans-
ing, which may prevent infection of the affected
aieas of skin mth pyogeiw bactona
Darjilinff. See BAINEOLOG\ (India,
Sufyfun Wateis)
DartOS. — The layci of Hiibcutaneous tissue
m the scrotum (.outlining much uiistnpcd
muscle, and forming a bac toi each testicle ,
it contracts under the influence of cold 01 of
nutation The name is deiivt-d fioin the (Ji
o«, excouatod
Dartre. — A genene name applied some-
what vaguely to vaiious skin dise<ises, including
especially heipes, pityriasis, and lichen, \vhich
\\ere supposed to be all duo to the same consti-
tutional state
Darwinian ism or Darwinism.
— Charles Dai win's theory of the oiigm ot
species, etc, in \vhich evolution by natuial
selection and suivival of the fittest is the
central assumption See HEREDITY Datwm'i
tubeicle is the projection on the in tinned maigin
of the helix of the external car in the human
subject supi>oscd to represent the tip of the ear
of apes and othei lower mammals
— Hamness (from (h
hairy), especially general congenit.il hanmcHs
(h^pcrtrichosis congcniti), indi\ idu.ils so affected
have been teimed "hairy men," "missing links"
of the Darwinian theory, " Esaus," and " homines
pilosi " , pilosism, polyti ichia, hirsntios
Date Of Delivery. See FCETUS AND
O\UM, DE\ELOPMENT OK (Mature Foetus), PREG-
NANCY, DIAGNOSIS (1'robatte Date of Confine-
ment)
Folia.— The ducd leaves of
Datura Jastuoui <ind Datui a Metel , they have
a bittei taste, a peculiar odour, and the same
action as stiamomum leaves (qv), they are
ofhcial in India and the Colonies, being described
in the Indian and Colonial Addendum (1900) to
the British Pharmacopoeia (1898)
Daturas Semlna-— The dried seeds of
Datui a fastuosa, they are described in the Indian
and Colonial Addendum (1900) to the British
Pharmacopoeia (1898), they have the same
action as stiamomum seeds (q v ) , and there is
a Tinctura Datura Seminum, given in doses of
5 to 15 m
DATURA STRAMONIUM
271
Datura Stramonium. /•>'«• STRA-
MONII FOLIA /STRAMONII S&MINA
Dat Urine.— An alkaloid ol)tained fiom
Datuta titianionium, etc, identical with h}os-
cyammo and isomeric with atropme ,V« ALKA-
LOIDS (Vegetable), SIRAMOMI Foi IA , etc
Daugllstl'8 Bread. - Patent aciated
bread made from floui by an admixture with
carbonic acid watei under pressmc by means of
Npecial machmciy
Davainea Madagascarlensis.
— A laro ccstode, found in Madagascai, Man
ntius, and Bangkok tiee PARASITES (fyWw/fx)
Davos Platz. *SV<? TiifcRAmnics,
HEALTH KESORLS (tiwit ttland)
DaX. H?e BAL\FOKM;Y (Ftame, Thai mat
Waters)
Day Blindness.— Inability to see (eithei
at all or without pain) in the daylight , hcmera-
lopia
Day mare. — A condition of exticme tenor
01 distress, resembling that seen in cases of
"night tenois," occuiiing in an individual in
the waking state , allied to epilepsy tiee NK,HT
TERRORS (Ntahtmat e) , RHEUMATISM IN CHILDREN
(Neivou* AJfwttoiH, Day Tenoi*)
Deaf mutism.
INTRODUCTORY TO
MORIUD AN\TOM\
TEST IN<I OF DEAF MUTES
DlSl'RIUUTION OF DbAtMUllSM
DIAGNOSIS, PROGISOSIS, AND T UK ATM EM
OCCUPATIONS OPEN TO
I ll)l()U\
271
27 2
272
273
273
274
273
Xce also MENINGITIS, TUBERCULOUS AND POS-
TERIOR BASIC (P)o</now)
B\ dumbness we mean the \vant of po\ver to
.irticulate sounds All classification*) of cases of
dumbness are open to objection The following
two great divisions require special discussion -
1 Deafmutism or deafdumhness Dumbness
due to deafness
2 Dumbness associated with idiocy or de-
mentia
In addition to those, dumbness may be the
result of damage to the brain, eg aphasia, \ihere
there is sometimes cntne loss of speech, due to
a lesion in the third loft-frontal convolution,
apoplexy, bleeding on or into the brain , embol-
ism of a ceiebral artery , tumour of brain, etc.
Further, dumbness may be part of a more
general paralysis, such as lead paralysis, or it
may be due to pressure on the hypoglossal
nerve. Dumbness may also be a featuio of
hysteria
Deafmutism — The deaf and dumb are not
otherwise physically peculiar Placed under
similar conditions they develop equally \\ith
healing children At si\ or seven, when the
deaf child enters school, he is like the heating
child of two or thice years, and it is a curious
fact that his head is half an inch less in cncum-
feicnce than the healing child of the same age
Such is the influence of heai ing on the develop-
ment of bxam '
All deaf mutes are not stone deaf Most heai
loud noises or shouting, some distinguish vowels
and consonants, and 1 have had them beat tune
accuiatcly to music of all kinds when the sounds
of the phmiojnaph were conveyed to then eats
by the tubes belonging to the mstiumcnt,
although their eyes vvcic cox end caiefully to
pi event their seeing the manipulations about
the instrument But all deaf mutes aie so deaf
that they cannot heai ouhnai y talk and cannot
be taught \\ith hearing clnldien Speech is
noimally the icsult of heai ing, and when theie
H little' oi no healing the child vvill not speak
Further, it at fom, h\e, 01 six }eais he lose his
healing, his speech will leave him
DeaJmntivH is tttJtei lomjenital ot ac^uned —
In Biitam about 50 pel cent of the cases belong
to each of these two gicat classes But in some
paits of Amenca and the continent of Km ope,
epidemic eerebial spinal meningitis raises the
piopoition of acquued cases, which with refer-
ence1 to the congenital cases bcai a ratio of ncaily
tuo to one Still, although epidemic meningitis
is not common in Biitam, diseases of the head,
ol \\hich meningitis is the chief, aio responsible
for .1 large number , next to meningitis as causes
oi acquit od deafness comes scarlet fevei, and
after this disease measles These three diseases
account for nearly 60 pei cent of 0111 cases of
acquired deafness Now, when these diseases
tike auay hearing, the) often take it all away,
and, f uithcr, they often damage the intelligence
of the child in other \vays, hence come these
two facts —
1 When testing the healing of the deaf and
dumb it is common to find a congemtally deaf
child \\ith more hearing than a child who has
lost Ins hearing after birth
2 Teachers often find the congemtally deaf
child bright and clever, and the acquired deat
mute slow and stupid
Congenital deafness, as we have seen, accounts
foi about half the number of cases of deaf mut-
ism in Britain Many cases supposed to bo duo
to disease m early life are really cases of con
genital deafness This mistake is due partly to
the fact that parents are slow to admit the
presence of a family defect, and partly to the
fact that diseases occurring in ^ery early life
arc apt to be ci edited with whatever defect is
discovered later Thus falls, frighJs, etc, are
often credited with having caused deafness which
has existed from birth
In every institution examples may bo found
of deaf-mute children who have one or two deaf
272
DEAFMUTISM
parents or grandparents, and of two 01 moio
deaf-mute children belonging to one family
Statistics horn Hutish institutions ha\e been
fully dealt with in the authoi's chapter on
congenital deafness, " Deaf mutism, a Clinical
and Pathological Study," but it is intctcstmg
to examine statistics so entnely di voiced from
European influence as those of Japan mubt l>c
In the Ktjiott of the ToAto Institution ioi 1S9(>,
Mi Shirnpachi Komshi, dircctot of the school,
says, "Out oi si\ty-siv dumb pupils in this
school, tht'ic is one pupil whoso grandfather was
deai, one whose giandtathet's brothel was deaf,
and one whose lathei's grandfather was deaf
The numbei oi pupils who inherited dumbness
dncctly f i oui their patents is only thice, whilst
fourteen dumb pupils ^cie born oi patents who
nun led their cousins" Now these statistics
are quite parallel with similar ones from Biitish
and American institutions Then take the
following instances fiom the Glasgow lecords —
1 In the F family there are 10 children — 5
deat bom, and 5 heating The patents heai
'2 In the Ayrshire family there ha\eoccuued
(lining the ptesent centuiy 42 cases oi congenital
deafness , deaf - mute children are still being
bom into this fannl), «ind one is being educated
in the Glasgow institution now Theie spring
trom these statistics, lot the fuller consideration
of which the authoi's woik maybe consulted,
these two conclusions —
1 The c ongemtally deaf and those related to
them should not matry
2 Tntermatriage of blood iclations should be
strongly discoutaged
Tht Jit\t jtosition— thill the c ongemtally deaf
should not marry — is generally conceded by
those who work amongst the deaf, but the
present atrangcments fot the education of the
deaf, and their management in missions and
institutes fot the deaf during the petiod of
adolescence, is eminently titled to cncouiage
union between the (ongemtally deaf If not
during the school period, at least dunng the
period of adolcsccme, eveiy thing should be
done to discoimigc the association of the deaf
and dumb with each othei, and the danger ot
their meeting with those snmlaily afflicted
should be constantly kept bcfoie the congem-
tally deaf by those in charge of them There
are a lew b.ul families, to the members of
which it would be well to prohibit marriage
altogether Here is an example It is taken
from the Sheffield Evening Telvjtaph for 26th
June 1896 — "At an inquest yesteiday on
William Earnshaw, fifty-nine, a St Pancras
saddler, it was stated that the relatives could
not identify the body, as the wife and sister
were blmd'deaf, and dumb, and that the four
children weie deaf and dumb The deceased
was deaf and dumb, and was so when he was
married " Now such families as this are re-
sponsible fot a largo number of the deaf mutes
in out institutions I do not think it would be
wtong to prohibit marriage to the members
of such families 1 do not say that all the
congemtally deaf should be fot bidden marriage,
but where the defect is so pronounced that
the result is a foiegone conclusion, 1 think the
interests of the State should go bcfoie those
of the individual
The \eiond jto^tion- — that blood relations
should not inteimatiy — can hanlly be dealt
with by legislation, and if the facts weie known
thete should be no need foi legislation On the
othci hand, piohihition involves no injury to
an} one The facts die these The intei-
maruagc of cousins will emphasise in the oft-
spting whatever defects ate chai.utcnstic of
the family, theie is no chance of these being
neuttaliscd or dying out as the tesult of the
mamagc, as is usually the (ose when persons
pteviously 11111 elated get manied Given per-
fectly healthy cousins with no tendency to any
disease, inteiinninage would not do harm to
the offspring, and might com en ably do good
JJut as sudi cousins do not exist, mam age
between cousins is often disasttous and is
always imptudcnt
THL Moitjjii) ANAIOMI OF Du \r\uriiMi —It
is cutious that malfoimation of the external ear
is seldom found in deafmutism which so often
is congenital Probably not even in one pet
cent of deaf-mute dnldicn docs such a con-
dition exist In the middle ear pathological
conditions are much moic common, but these
consist of the usu.il changes — perforations of
the membiane, loss of the ossicles, necrosis
of the pettous pottion, etc But, of course, it
is not to these that the deafness is due The
.icqimed deafmutism is almost always due to
disease of the mtetnal eat which has spiead
f i om the middle ear, and caused inflammatory
changes involving destruction of the mem-
branous labyimth and of the neive structures
which it snppoitb In a number of cases the
danger appears to approach from the side of the
hi am — meningitis, — and more lately still, the
damage to the inner ear is due to a primary
la}>_> rinthitis
In congenital deafness the changes on \vlnch
the deafness depends are not essentially diflereut
from those described above, except in cases
which depend on attest of development or
malformation They consist of obliteration of
the normal nervous structures by inflammatory
new formations, chiefly osseous It is not
possible to estimate the ptopottioii of eases due
to malformation, but it is undoubtedly smaller
than was formerly supposed After a series
of years it cannot 111 many cases be decided
whether a structure has been obliterated or
has not been developed
TIIE TKSTIXCJ OF DEAF MUTES — It will be
found impossible to apply reliable and accurate
tests to very young deaf mutes The presence or
DEAFMUTISM
273
absence of hearing may bo determined, but the
amount of it cannot bo ascertained till the deaf
child has been HO far educated as to undci stand
the nature of the tests Hence it is not worth
while testing doaf children till they have been
a year at school. In the mtcival, of course,
the teachei has discovered «\ny cases in which
much hearing remains The best tests are u
dinner-bell so arranged that one note may be
struck at a time, and the human voice used
in thu production of vowels and consonants
liczold1 of Munich used the whole gamut of
the musical scale, and made a veiy interesting
discovery, \\7 that in some cases islands ot
hearing exist in the simounding ocean of silence
or deafness Those islands, of course, repiesent
the less injured pieces of the cochlea, and
sometimes include only a note or two, some-
times a half or a whole octavo These observa-
tions of Bczold give a veiy strong support to
the Holmholtzian theory of the function of the
cochlea, but as the islands seldom coincide with
the tones of the human voice, and as the con-
tained tones aie seldom very distinctly heard,
they will probably be of little use in the practical
training of the deaf
THE DiHTuiuunoN OP DK \FMUI ISM — The pro-
portion of the deaf to the hearing varies in
different coiintucs, but it is governed by causes
which operate alike in all countries The
following table gives a leuew of the deaf-
mutism in vanous countries It gives the
number of deaf mutes pei million living as
well as the ordinary rate —
lUtt pir
million
Switzerland 2452 or 1 in 408
Austiia 1307 „ 765
Hungary 1263 „ 792
Sweden 1023 „ 977
Prussia 1019 „ 981
Finland 1018 „ 981
Canada 997 „ 1003
Norway 930 „ 1052
Germany (without Prussia) 931 „ 1074
Portugal 750 „ 1333
Ireland 715 „ 1398
India 685 „ 1459
United States 659 „ 15U
Denmark 650 „ 1538
Greece 646 „ 1548
France 626 „ 1600
Italy 537 „ 1862
Scotland 530 „ 1885
Cape Colom 525 „ 1904
England 489 „ 2043
Spam 459 „ 2178
Belgium 445 „ 2247
Australasia 371 „ 2692
Holland 335 „ 2985
Ceylon . 231 „ 4328
The causes which determine these variations
1 Das ffbnermbgcn der Taubstummen, 1896
VOTj II
in tho deaf-mute rate are various. Speaking
generally, in prosperous flat countucs like
England, where the population is well fed and
housed, where infectious diseases are carefully
treated, and where communication is rapid, the
deaf-mute rate is moderate On tho other
hand, in a mountainous country like S\\it/er-
land, sjiarseness and stasis of the population
make for met case of consanguineous union and
.in increase of congenital deafness, while the
grcatci difficulty ot combating tho ravages of
the exanthemata makes for an increase of
acq uned deafness, and tho deaf-mute rate tends
to he high Snnilaily neu colonies like Aus-
tiaha have a lower deaf-mute rate than the
old colonies like Canada, consanguineous union
being less common
DIAGNOSIS, PKOONOSIS, AM* TREAT MEM- OP
DKAFMUIISM — When a dumb child is brought
to the surgeon, the first thing he should do is
to test his hcaimg The child is, say, three
yeais old, and his inothei i" dissatisfied with his
speech She does not think him dumb He
says Ma-ma and Pa-pa, and the mother thinks
this proof that he hears Further, she has
noticed that loud sounds, such as the slamming
of a door 01 the fall of a shovel, startle him
Now the facts are that the child says Ma-ma by
imitation, he lip-reads, and he turns at tho loud
noise, either because he hears nothing but very
loud sounds, or because he feels the vibration
earned along tho floor or \vall when the door is
slammed It is generally easy to settle the
question of the presence or absence of hearing
Kngagc tho attention of the child with your
watch 01 knife, and let an assistant slip un-
noticed behind the child's back with a gong or
a bell, and while it is being sounded watch tho
< hild's face If ho hear he will turn, or wince,
or wink, or in some vay show by his expression
that he has been affected by tho sound If he
show nothing of this kind he will be too deaf
for teaching in the schools for hearing children
The more accurate testing of deaf mutes is
mtci eating and has been rcferied to, but this
test is enough for the child as he is nrst bi ought
before the suigeon The ^rojrnosi* in such
cases is almost uniformly bad as far as the
hearing is concerned It is best to tell the
mother that her child will bo a deaf mute, and
will require to bo educated by special methods.
In tho meantime she may bo made to look upon
the development of hearing as a possibility, and
she should be encouraged to ply the cars of her
child with all sorts of pounds, especially with
sounds of all pitches, e g. the notes of the violm,
piano, concertina, etc, with the view of en-
couraging such development But this is rare
I have seen such growth of hearing in one
instance, or rather in two children in one family,
but it is not common enough to set before the
parents of deaf children as a probability Apart
from the deafness, tho prognosis in older ehil-
18
274
DEAFMUTISM
dren should be based on the evidence of natural
ability shown by the child Cougemtally stone-
deal children often make bnght pupils Semi-
deaf children who have had their hearing damaged
by meningitis and scailet fever are often dull and
make little progiess
The treatment of deajntwtum divides itself
into surgical and educational Five to ten per
cent of deaf-mute children have chronic sup-
purative disease of the middle ear with or
•without necrosis of the ossicles 01 internal
tympanic wall when they are bent to bchool
These cases lequire treatment on ordinary
surgical lines But a far largei number of
deaf-mute children have enlarged tonsils and
post-nasal adenoids Now the removal of those
growths will not make the children hear, but if
any serious attempt is to be made to make the
children speak well, these growths should be
removed wherever they are well marked. As
deafmutism depends in nearly every case on
destruction of or absence of the internal ear,
efforts having for their object the restoration of
hearing will necessarily fail But the question
arises whether an attempt should be made to
use the partial hearing which so many deaf
children have Now this, like almost all ques-
tions connected with the education of the deaf,
must be decided with reference to the circum-
stances and position of the child If the
parents can afford it, the child should have a
teacher all to himself, arid with the help of
conversation tubes, phonograph, etc , everything
should be done to teach the child through
his auditory nerve Hut in a schoolroom, with
classes of six to twelve in number, this is clcaily
impossible Further, teaching by conversation
tube is resented by teacher* , they do not like
the shouting involved A few teacheis in this
country and in America have tued this acoustic
method, and find that the speech of oral pupils
is improved in about 15 or 20 per cent of the
cases by this method of teaching If carefully
and persistently used this method may be made
a great help to oral pupils Seldom will it be
possible to teach the deaf-mute child by the
auditory nerve alone
On the general question of educational methods
it is not the intention of this paper to dilate at
length, but it may be stated that in the opinion
of the wnter the otal method should be adopted
for the preservation and perfecting of the speech
which the semi-mute have still left. Also when
there is any great remnant of hearing the oral
should be combined with the acoustic method,
and in these two classes of cases the semi-mute
and the semi-deaf signs should be excluded as
much as possible. But there remains the great
class of tlfe true deaf mutes — those who have
never spoken and who have no hearing which
can be used These form two-thirds or three-
quarters of the entire number of the deaf and
dumb. When one of these children can be
taught in private and have the entire attention
of a teacher, the oral method will generally give
results gratifying to its parents and of great
benefit to the child, and it should only be given
up for the finger method if fair progiess is not
being made with the education of the child.
In an institution many children, perhaps most,
will do better on the finger method or on a
combined method For the first year the wnter
thinks all deaf-mute children should be educated
on the oral method At the end of this period
the teacher will know if the child is likely to
make a good oral pupil, and will regulate his
future accordingly This imolves two schools
— an oral and a fingei school — in eveiy large
centre of population, from the foimer oi \shich
all signs aie as far as possible excluded Like
the hearing child the deat mute should be sent
early to school, and in this country both law
and expediency have fixed seven years as the
best time for beginning education at school.
For Scotland m 1891 and foi England in 1894
an Act came into foicc, the chief provisions of
which are these — Education is compulsory from
the age of seven to that of sixteen, and the
duty ot seeing that this is carried out is laid on
School Boards or the school authorities of the
parish ulieio the parents of the deaf children
lesidc The authontien, in carrying out the
Act, are at hbeity to pi o vide a school of their
own, or they may send the child to a certified
school oi institution outside their bounds, the
parents being allowed a reasonable amount of
liberty in the choice of a school Whcie tho
patents from poverty aic unable to pay the
fees, the school authority is required to pay,
not only for the education, but also for the
maintenance of the child
LlSl OF T&UJKS, MC , IN WHICH JHE DlSA* AND
DUMU AUK KMl'LOYKD
(Keport of the Glasgow Mianon to the Dtajand Dumb, 1804 95)
Artist
Ait Metal Workeis
1 Brought foiward
2 Diesmaker
83
2
Bakers
4
Domestic Servants
3
Beltmakcr
1
Draughtsmen
6
Blacksmiths
2
Diessmakors
10
Boilermakers
6
Dyer
1
Bookbinders
20
Engine Fitters
6
Bookfoldeis
4
Fancy Boxmakers
6
Boxmakers
Biass Engravers
7
Fishing Tackle Makers
Gardeners
2
2
Brass Finisher
1
Glass Decorators
3
Bmklayeis
2
Glass Stamers
2
Brickmakers
2
House Joiners
3
Brushmakers
4
Iron Woikers .
Butcher
1
Jewel Case Makers
2
Cabinetmakers
2
Jeweller
1
Calenderer
1
Labourers
16
Capmaker
1
Lamplighters
2
Carpet Designeis
Caulkers
5
3
Lithographic Artists
Marble Cutters
15
2
Chairmaker
1
Mill Workers
4
Clerk
1
Moulders
3
Compositors
Confectionery Worker
5
1
Needlewomen
Pamteis
8
2
Cooper
1
Patternmakers
4
Carry forward .
83
Carry forward .
190
DEAFMUTISM
275
Brought forward
Punemakora
Rivetei
Saddler
Sculptor
Ship Joineis
Shoemakers
Silver Engiaver
Tailors
Ticket Wilton
Carry forward 225
Brought forwaid 225
Tinsmiths
Umbiella Makers
Upholsterers
Washerwomen
Weavers
Wood Carverb
Wood Kngravei
Wood Turner
Total
3
5
1
1
1
258
DUMBNESS FROM I DICK1 Y — DlimbllOSS IS H
necessary result of great deafness happening
early in life, and of congenital deafness, but
dumbness is no necessary concomitant 01 result
of idiocy. Most imbecile children can be taught
to speak Dr Ireland says • " The lower classes
of idiots never learn to speak at all Out of 103
cases of \\hich I have notes 36 \vere found mute*
on entry, and 67 could speak more or less The
average time at which they began to speak \vas
4 years and 3 months Only four \\ere noted as
having spoken at one yeai " Childicu ot this
class, when they aie dumb, are so because they
have no ideas to express, and speech develops as
education piocccds At Laibert, Stiihngshiie,
Mr Skene, the superintendent of the institution
there, showed the writer a cretinous idiot who
had not only impioved in giowthand in geneial
condition very lemarkably, but whoso speech
showed an equally satisfactory development
under the use of thyroid gland and extract, and
this treatment promises no less bulliaut results
when applied to cictmous children than it has
given in myxoxlnna Two classes of idiotic
children lemain to be mentioned — the deal -mute
idiot and the aphasic idiot. Both of those should
be educated as idiots, and not in schools for the
deaf and dumb The aphasic idiot or the idiotic
aphasic hears perfectly, but is not intelligent,
and does not do well in the schools for the deaf
and dumb The deaf-mute idiot is hardly cap-
able of education in the ordinary sense at all
Most idiotic childien have good musical ears, and
perform and sing in action songs vciy well
Deafness. Xee ALCOHOLISM (Iwtourn-
tton, Dulness of Hearing) , AUDITORY NERVE AND
LABYRINTH (Physiology, Test, Net ve Deafness, etc ) ,
BRAIN, TUMOURS OF (Localistnt/ Symptom**,
Heating), BRAIN, CKRBBBLLUM, AFFECTIONS o*
(Tumour, Auditory Nerves) , Or IMACTERIC IN-
bANiTY (Clinical Fauns, Deafnew) , CRETINISM
(Causation) , KAR, EXAMINATION OP (Simulated
Deafness), HEREDITY (Inheritance of Disease,
Deafness), HYPNOTISM (Exjwiment'tl Phenomena,
Deafness) , HYPNOTISM (Therapeutic Uses, Deaf-
ness) , MENINGITIS, TUBERCULOUS A\D POSTERIOR
BASIC (J'toijnosis) , MENINGITIS, EPIDEMIC CERE-
BRO-SriNAL (Symptoms, Ear) , NOSE, POST-NASAL
ADENOID GROWTHS (Symptoms), PHYSIOLOGY,
THE SENSES (Hearma), RHEUMATISM, CHRONIC
(Clinical Features), SPINE, SURGICAL AFFEC-
TIONS (Caisson Disease), SYPHILIS (Children,
Ear), THYROID GLAND, MEDICAL (Mytoedema,
Special Senses) , TONSILS, DISEASES OF (Enlarged
Tonsds, Symptom*)
Death. See ABDOMEN, INJURIES OF
(Cauwv of Death) , ADOLESCENT INSANITY (Nerve
Breakdown ami Mortality Statistics) , ANAJS-
THEHIA (Death* under Ether, under Chloroform) ,
AN >,si HBHIA, COMBINED ANESTHETICS (A C E.
Mixtme, Death vrultt) , ASPIHXIA (Causes),
BRAIV, TUMOURS OF (Prognosis) , BREATII
(Detet HU nation of Death) , CLIMATE (DeatltrRate
in Cold Climates) , DEATH, SIGNS OF , HEART,
MYOCARDIUM ASD ENDOCARDIUM (Effects of
(larditu Distaie, Sudden Denth) , MEDICINE,
FORENSIC (Certificate of Death), MEDICINE,
FoRKvmr (Su/nt of Death) , MEDICINE, FORENSIC
(Diath tiom Ln/htnmy, Elettuc Current*, Stai-
vation,Colfl,Atphyxia), POST-MORTEM METHODS ,
PREGNANCY, DIAGNOSIS (Death of Fattus) ,
PREGNANCY, INTRA-UIERINE DISEASES (Death of
FtKtin) , PRFGNANCY, AFFECTIONS AND (COMPLICA-
TIONS (Death) , PUERPERIUM, PAIHOIOGY (Sudden
Death, Cause,*) , TEMPERATURE (JPre - Adonic ,
Affft Death) , TOXIOOIXKA (Pott-Mortem Apjjear-
(ince* of Poisons), Tvi'iits FEVER (Death in),
VITAL SiAns'iics (Death*), etc, etc
Death-Rate. — The ratio between deaths
and population, stated (commonly) as so many
deaths (e <j 14) pei annum pci 1000 of the
population See VITAL STAIISIICS (Death*)
Death • Rattle.— The tattling sound
caused by the bieath passing through mucus in
the thioat of the dying , is not an invariably
certain sign ol impending death
Death, Signs Of.— The distinction
between the quick and the dead is not always so
absolute as might at fiist appear Long after
wh.it is called the moment ot death vital phe-
nomena continue in some of the tissues of the
body, and even if wo set aside all cases of
Indian fakns and Colonel Townsends, theie
icmains a sufficient residuum of cases of peisons
presumably dead after waids ieturnm£ to life
to raise in the minds of some a moibid fear of
being buned alive The conditions which may
thus most nearly resemble death .11 e syncope,
asphyxia, and trance
The principal signs iclied on as piovmg that
death is real and not apparent aie —
1 Entile Cessation of Circulation and Re-
spiiatwn — The entue cessation of all lenpnatory
movement foi a period oi five minutes is itself
sufficient pioof that death is) real and not ap-
parent, but the test of auscultation should be
applied for a sufficient period to make sure that
the action of the heart (/» intuni vivetiset ultimum
nun iens) has really finally ceased. The popular
method of testing for the continuance of respira-
tory movements consists in holding a cold mirror
or a fluff of cotton before the nose and mouth.
276
DEATH, SIGNS OF
If rospiratoiy movements are still going on, the
mirror will bo dimmed or the fluff of cotton by
its movement w ill betray the passage of the air
To test the cessation of the ciitulation it has
often been suggested th.it a small vein should be
opened A neater test is that proposed \t\
Magnau, who lecommendod that a hgatuie
should be tied firmly round a limb It circula-
tion was going on e\en blow]} the limb beyond
the ligature would giadually become congested
2. The (-ofjlinf/ of the Modi/ — Under ordinal y
circumstances a dead body is quite cold in iroiu
twehe to twenty horns after death The late
of cooling is, however, modified by many cncum-
stances Thus a fat body will cool less quickly
than a thin one A body naked or exposed to
cold air will cool nioic quickly than a bod\
wrapped in woollen co\enngs or simoundcd by
a warm atmospheie In watei a body will cool
nioio rapidly than in an of the same tempcia-
ture It is said that when death occuis from
hyperpyrexia the temperature may even continue
to rise foi a shott time after death
3 Cttdavet ic Rnjuhty — Rigor Mot ti s — Aitei
death the muscular system typically passes
through three stages Fust, there is a stage oi
flaccidity in which the mustlcs letam then
power of contracting on electric stimulation
Muscles which weie contracted in the act of
dying may pass into a condition of tadavciic
spasm instead of relaxing at "the moment of
death " The second stage is that of i igor mortis
The third is that of iclaxation and incipient
putrefaction Kigoi mortis usually sets in six
or eight horns after death, and may last for thiee
to siv or seven days Its usual duration is
about twenty-four hours It commences in the
muscles of the neck and lower jaw, and passes
on into the muscles of the upper limbs, chest,
and lower limbs It passes off m the same
order Rigor moitis is a phenomenon analogous
to the coagulation of the blood It is due to the
coagulation from the muscle plasma of a pioteid
termed myosin, and the process is accompanied
by the bbciation of carbonic acid, and a change
from alkaline to acid in the icaction of the
muscle substance The period of onset and the
duration of ngoi moitis depend chiefly on the
degree of exhaustion of the musculai tissue
When death has occurred from convulsions 01
by accident, for example, during prolonged and
excessive muscular exertion, rigor comes on
veiy rapidly and passes off correspondingly
quickly
4 Hyposlan* — The gravitation of the blood
to the most dependent parts of the body results
in the post-mortem staining which begins to
appear in from eight to twelve hours after death
If the body has been tying on a hard table the
parts m actual contact with the table, such as
the buttocks and scapular regions, may be quite
white, while the parts immediately surrounding
are deeply stained. Hypostasw must not be
confounded with ecchymosis, in which condition
the blood is actually extravasated into the sub-
cutaneous tissue The distinction m a doubtful
case is easily made by making a small incision
into the discolouied pait
B The lustre of the eye is veiy quickly lost
attei death, and the tension of the globe falls so
that the cornea feels flaccid These changes.
occasionally take place even before death , for
example, when death is duo to malignant cholera.
6. Thf /Mi/i— Aftei death the skin loses its,
noimal elasticity It undergoes striking altera-
tions in colour The hist change is a geneial
pallor of the whole surface A little coloui may,
how e\ er, be left in dilated venulcs Kcehymoses,
of course, retain their colour Latei, the dis-
coloiation due to hypostasis appears, and this
is followed by the colour changes associated with
putief action
7 Putrefiutwn — As rigor mortis pisses oft
the putrefactive c hanges w hit h end in the com-
plete dissolution of the body make then appeal -
ance The hist signs oi putief action are that
the limbs become supple, a faint odom becomes
noticeable, and a greenish discoloration appeals.
on the abdomen, and later on the chest, face,
aims, and legs The progicss of putief action
may bo limited to a grcatci 01 less degree under
suitable cucumstances by the occurrence of
mummification 01 the formation of adipocete It
is said th.it putief at turn may be gieatly delayed
in the ladies of persons who have been arsenic-
eaters
Death Struggle.— The ayrmv 01 the
pre-mortem convulsive throes or pangs /See
AGONY , POSI-MOHTKM METI HODS (Agtmal Intuh-
\uttcejition)
Debility- — Weakness in general, 01 weak-
ness of mind (delnlita* animt) 01 memory
(debilitav memorur) tiee NFUHAHI'HKMA, HEAD-
, etc
Decapitation. »SVv LA noun, OPERA-
TIONS (JSmtsryotomy, Trunk Ptewntatitnu)
Decapsulation, Renal.— The split-
ting or separation of the capsule of the kidney
as recommended and earned out by EdebohU
(1899) m cases oi Bnght's disease and (aftei-
wards) in puerperal eclampsia, its value has.
not yet been established It is sometimes as-
sociated with incision of the renal substance
(nephrotomy).
Dechery Cautery. <sv« CAUTERY
(Thermo-Cautery)
Dechlorlnatlon or Dechlorlda-
tlon. See also URINE, PATHOLOGICAL GUANOES ;
DROPSY — Dechlormation, or restriction of the
amount of salt consumed to the minimum con-
tained m the food elements, has recently been
introduced into therapeutics in the treatment.
DECHLOBINATION OR DECHLORJDATION
277
of diseases attended by dropsy, and, in particulai,
Bnght's disease. Thanks to thu labouin of Widal
and othciH, the method has been elaborated on
a rational basis, and incidentally much light has
been thrown on the s«ilt interchange of the body
as well as on thu natuie of oedema Contrary to
popular belief, there is no e \idenco that the
almost umvcisal piactice of adding salt to io(xl
w neccHsary to health, without labounng this
point, it may be said th.it among the less
civilised races thcie aie many exceptions to the
rule, and th.it the alleged instances of ill-health
tallowing privation irom salt bieak down on
oaieful sciutiny The actual lequiiement oi
salt, as estimated by the amount evicted in
fasting conditions, is about Ggiam daily, and
this loss is more than i enlaced by the amount
—1 3 to2giams — naturallypieseut in an aveiage
mixed diet Kxpenments sho\\ th.it in health
the body is in a state oi chlonde equilibrium,
the amount eliminated daily coiiesponding to
•what is ingested All the tissues of the body
sire bathed in saline fluid, and it is inipeiatwelv
ncccssaiy that the osmotic piessure, 01 con-
centration, of this should remain constant The
ncgatue action oi " physiological " salt solution
on tissue cells as compaied with the delctcnous
effects of stiongei and weaker solutions is an
illustiation of this Vaiiations in the quantity
of halt in the l>ody must tliereioie be compen-
sated foi, and this is done, partly by the le-
tention of enough watei to keep it m solution
of noimal stiength, and partly by the elimmutory
action of the kidneys If a healthy man be
placed on a diet tiee fiom added salt he con-
tinues foi se\eral days to eliminate a quantity
exceeding that ingested, losing weight the
while, at the end of that time chlonde equi-
librium— / c output equals intake — is lestoied,
and the weight icmains stationaiy. The addi-
tion of a fixed lation of salt causes the weight
to rise again , thcie is a corresponding letention
ofchloiides as measuied by the output befoie
uquihbiium is le-estabhshed From such ex-
pcnmcnts it has been sho\\n that about 12
giams of sodium chlonde. and 1 5 to 2 kilos oi
water repicsent the floating quantity lost by a
normal subject in the piocess of dechloimation
Owing to the ability of the kidnc} s to excrete
chlorides ficely, large dosos aie tolciated in
health, yet the power of even the normal organ
has a limit, and the habitual consumption oi
excessive quantities of salt beyond the icnal
capacity has been known to lead to retention oi
salt, giving rise to o;dema from the excess oi
water required to keep it m isotomc solution
In many forms of nephritis the kidneys lose
their permeability to sodium chlonde, the bait
is retained in the tissues, and dropsy ensues
This has been abundantly venhed by experi-
ment Patients with Bright's disease, swollen
with dropsy, when put on a diet containing no
added salt often lose weight steadily, the
oedema also vanishing On adding salt the
weight rises, and the dropsy leappears It IB
Pound in such a case that oil each addition
or subtraction of salt with its coi responding
use and fall in the weight curve theie is a
definite level at which visible oedema makes its
appearance Widal calls the interval during
which the weight is iisirfg towaids this point
the jne-udeniatoui p&iotl, it leprcseuts the
iccumulation of fluid in the viscera We need
not discuss the i elation of stilt retention to the
syudiomo of ma;mia, the evidence that it is
lesponsible for the ncivous symptoms is less
tangible than its causal connection with oedema
It must, however, be said that in removing
ad i' ma by dcchloi inatum we have more than a
ymptomatic tioatmcnt The kidnejs, like the
nthet \ isceia, sufiei fiom the cflccts of interstitial
oedema, and theie is icason to bclie\e that m
curing this lenal uxlcma we bieak a link in the
chain oi a vicious < ucle, in which the inadequacy
of the kidney produces a ien.il lesion which still
iuithei impans the efficiency oi the organ.
Whatexei be the piecise explanation, it is
ccitain that a diopsical patient, whose kidneys
aie nnpcivioiis to veiy small quantities of
chlonde, may, after dechlormation, regain the
powei of eliminating it in consideiable amount,
uiid with this theie may be maiked diminution
in the albumen passed Dechloimation is
occasionally attended by neivous symptoms
lesemblmg those of imeima , these, however,
aie raie and transitory
The practice of dechlormation is simple, and,
contraiy to what might be anticipated, patients
seldom lebel against being deprived of salt
Milk contains 1 6 grams of salt pei litre, which
is equivalent to about 5 G grams in an average
daily ration Although this consideiably ex-
ceeds the proportion natuially present in a
mixed diet, it is much infeuoi to the quantity
habitually consumed as added salt (15 to 20
giams), and piobably the efhcacy of milk m the
tieatment of nephntis is as much due to its
comparative poveity in chlorides as to any
special attiibute of its pioteid content In
stiict dechloimation, howevei, recourse must be
had to a mixed diet, w hich may be selected from
among the following, cooked without the addi-
tion of salt — Fiesh meat of all kinds, fresh-
water hsh, eggs, fresh buttei, cream, potatoes,
and farmaceaj generally, sweets, vegetables, and
fruit The only aiticle which lequircs special
fabrication is bread , as ordinal ily baked it con-
tains from 8 to 1 per cent of salt , this, therc-
foie, must be omitted Soups, sea-water fish, all
forms of salted 01 pieseived foods, cheese, and
milk arc piosciibed In practice JVidal allows
from 100 to 200 grams of meat daily, with
farmacete, etc , as the appetite demands.
Patients subjected to dechlormation should
be kept in bed until the weight ceases falling
and remains stationary Should dehydration
278
DECHLORINATION OR DECHLORIDATION
be slow, it may be aided by diuretics, paiticu-
larly theobrommc To gauge the amount of
fluid (and chlorides) lo&t by the body caieful
daily weighing is essential, and leplaceschlonde
estimations
Dechlormutum has been successfully cmploj ed
in dropsical affections of all kinds, such as caidiac
and hepatic disease, oxlema of the legs from
exertion, phlcgmasia, etc The rationale of it 8
action is the same in all such cases It has
also been employed in epilepsy, but on quitr
other grounds, the hypothesis being th.it by
rendering the tissues pooi in chlorides the
bromide intioduced is enabled to act moie
effectively
Decld Ua. See AHDKTION (Cause*, Matt) nal,
Deculttal Disease), CADUPA, ErroricGEhiAiioN,
FOETUH AVD (HUM, l>B\KfX)l>MBM <iK (Dt'lldltft) ,
MOLE, MOLAK PRKUKAMJI (Moltt, Cariiwu) ,
PUEUNANC\, 0\UW AM) DuriDUA (A/flttOHS of
the Decidua) , PKUJKAM^, DISRASESOI* PLACENTA
AND CORD (Diwtw of the Membrane.*, Jhndual
Endometntn)
Deciduoma Mai Iff num. See
ABORTION (Imomple. te) , CIIOKIOMA , OHORIOV-
EPITHELIOMA, FALLOPIAN TUBES (Tumour*,
Deciduonui) , LAIIOUR, Pos r - P \R-I un Hi- MOK-
RHACJK (Second™ y) , 1'unirEim.M, PATHOLOOI
(Sartoma- Deciduo- Cellulate M Deciduoma
Malignum) , S\NT\IIOMA, TLMOURS (Epithehnt
Group)
Declaration, Dying. See MEDICINE,
FORENSIC (Dyiny Detlaration**) •
Declination. — Deviation, also the le-
nussion of a disease or of the paroxysm ol a
disease
Decline of the Birth -Rate.—
A phenomenon of the close of the nineteenth
and the beginning of the twentieth centimes,
affecting all civilised countries, due doubtless to
several causes, but especially to the postpone-
ment of marriage till late in life (opsigamy)
and to the use of checks to prevent conception
and pregnancy In Edinburgh in 1871 the
birth-rate was 34 89 per 1000, in 1881 it was
32 23, m 1891 it \vas 28 25, m 1901 it TVRH
24 99, and m 1905 it \\as 22 99
DeCOCta.— -Solutions of Acgctable drugs
made by boiling in distilled nater for 5 to 10
minutes, and then stiaming, there are three
othcial dcfocta (Decoctnm Aloes Compositum,
Decoctunt Gianati Corftw, and Dfcoctum
I/tfmntoryh), and the dose of each is 4 to
2fl oz • '
Decollator, foe LABOUR, OPERATIONS
(Embryotwny, Decapitation) —An mstniment
shaped like a hook (sharp or serrated) or like a
key, used for decapitating the foetus m impacted
shoulder cases in labour, a decapitator (eg.
Braun's)
Decomposition. *SV MEDICINE, FOR-
E:»HIC (Siqtu of Death, /'ut refaction)
DeCUbitUS. — The attitude adopted by a
patient, paiticularly in bod, postuie in bed,
ulso means a bt'dhoic («is m myelitis)
DecUSSation. — A tros&ing of structures
(especially ot nerve falnra) m the foim of a X,
ey the docussation of the pyramids of the
medulla ohlonuata, of the fillet, 01 ot the pons ,
( hiasm
Defalcation. «sVe OUNSIMPAI ION (Plu/sio-
logicnl Cwwlntitiom) , DuJHsrioN AND META-
BOLISM ( Dffir cdtitm) , Pii\sioiA)<^, FOOD AM>
DioEM'JoN (Dfjaxnttim)
DefeCtlO Animi.— Montil deficiency,
dcliquium animi
DefeCtUS.— Delect oi absence of develop-
ment of any pait, e y defect us vagin.u or aticsia
\ aginao
Defervescence.— The sta^e of dodme
ot a te\t«i, nhich is eitlu'i shoit ("b} ciisis")or
pi oti acted ("by lysis"), the temperature and
pulse-iato fall, the skin acts freely, and then'
may be a pi of use diuresis or a diarrhoea
Defibrl nation.— The process by which
the hlu in is removed fiom the blood
Defloration.— The tearing of the hjmcn
and consequent destination ol the signs of
in a \\omun See FORENSIC MFDICINK
279
279
281
2ya
282
283
283
284
Deformities.
AUTHUODKSIS
CONGENITAL DISI OTA i IONS
(lEREBHAL AND Sl'INAL P\UAI VhlS
Itir-KKis
rr*.\DON-TRANSPLAM'Al l( >N
HAND AND FINC.ERH
Congemtal Deformities
Acfjmt ed Defot mitie*
LOWER EXTREMITY —
Tom—
llallux Valyw, Varuv, Jhyidu*
Hammer Toe
OtJter Defmmittet.
FOOT
CLUB-Foor— Congenital
Acquired
Flat-Foot
285
285
286
28G
286
289
290
292
LEO AND THIOII —
Bow-Legs . 293
Oenu ValgumtVaiwn, and Jiecurvatum 294
Coxa Vaia . 295
Ifo also BONE, DISEASES OF (OsttamyeUti*,
DEFORMITIES
279
Acute, Deformities ./row) , BURNS AND SCALDS
(Result*, Deformities) , CHEST, DEFORMITIES OF ,
CICATRICES (Contractiny) , HipJoitrr, DISEASES
OP (Crow-Leyged Dffotmity), LABOUR, PRECIPI-
TATE AND PROLONGED (1'ttvic Dffot mitiei) ,
MOUTH, INJURIES AND DISEASES OF THE JAW
(Mandible., Fracture, Dej&tmittj) , MUSCLES,
DISEASES OF (1'iewlohi/pet trophic Afyopathy, De-
formities), PALATE (Cleft Palate), PREGNANCY,
AFFEmONS OF O\UM AND DEflDUA (FwtttI De-
fo? mi ties from Amnwlic Adhewm^ etc ) , RI»L-
MATIHM, RHEUMATOID ARTHRITIS (Defon/utte«) ,
SPINE, SUROICAL AFFECTIONS OF (Lateial Cw»a-
twe, Anyulai Dejotmity, etc), TERAIOLO«I\ ,
WR\-NECK
AimiRODEMS
Definition — Aithiodesis is an operation de-
signed to fix a joint in a case of entne paialysis
ot the muscles in the neighbourhood of th.it
joint Its object is ankylosis cithci fibrous ni
osseous, and it is obtained by complete removal
of the articular cartilages
Indication* for O pet at ton — 1 When the
paralytic condition ot the limb is very se\ere
"2 In pooi patients who arc unable to provide
themselves with apparatus 3 When an ap-
paiatus is hardly tolerated and causes pressure-
sores 4 Not in spastic <ases nor in para-
lytic cases after acute febrile disorders, as
paialysis especially in zymotic diseases sho\vs a
strong tendency to rcuneiy ."> When t\\o
joints of a limb are hopelessly flail-like it is
advisable to fix one or both of them
Mtthoth — When the ojx'iation is done at the
knee 01 at the ankle, the t\vo joints most favom-
able, the essential pait of the proceeding is the
total removal ot the articular cartilage in such
a way that the l>onc surfaces are left in contact
At tJte Knee — The usual method is as follows,
and is (Mined out with all aseptic prci autions
An incision is made transversely across the
joint fiom one condole oi the femur to the
other, and passing acioss the middle of the
patelLi The patella is sawn through, and is
then turned upwards and downwaids The
articular cartilage is removed from the back of
the patella The joint is now fully exposed and
treated as follows — All the articulai cartilage
is carefully cut away with a gouge, scissors, and
sharp spoon or knife From the anterior sm-
faces ot the tibia and of the femur it is also
advisable to take a shco of bone off vertically,
so as to fix the posterior surface of the patella
denuded of its cartilage to them The bones
are now wired together in such a way that the
wire passes through the lower fragment of the
patella, then through the tibia, the femur, and
through the upper fragment of the patella.
The limb is now placed in the straight position,
and should bo kept immobile by plaster of
Paris for at least two months, and after that a
posterior splint is sufficient
At the Ankle — Considerable difference oi
opinion exists as to the most convenient incision
for the ankle, whether it should to anterior,
posterior, or external On the whole, the
anterior method gives the most loom Against
the anterior incision there are urged the section
of the aitery with dcpiivation of the foot of a
pait of its blood-supply, and the difficulty of
getting the tendons to unite satistactonly
Hut in practice these objections are not senous
The incision is made across the fiont of the
joint from one mull coins to the othei, dmdmg
all the soft itiuctmcs The joint is thus free!}
opened, and the .11 titular cartilages completely
icmoved It is not necessaiy to dissect away
every piece of the symmal membiane, since m
those cases in whuli it has been left its presence
has not inteifeied with the formation of bone
But no loose pieces ot caitilage aio to be left in
the wound, and none attached to the si u face of
the bone It is often advisable to ficely
" stipple " the bony surfaces The tendons are
then united and the wound closed The toot is
pla( ed in plaster of Pans at a right angle for
si\ weeks By this tune him fibrous union has
occurred To ensure osseous union, a difficult
pioceeding, the bones ha\e been united by <at-
gut, kangaroo - tendon, or ivory pegs Hut
absolute osseous ankylosis is not necessaiy, and
is lather to be deprecated at the ankle Close
fibrous union allowing about 10 degrees of
movement gi\es the best possible result In
cases of paralytic talipes calcaneus the best
incision is a curved one beginning behind the
peronei tendons, i mining dow n to the point of
the heel and then upwaids to the posterior edge
ot the flexor longus polhcis The nap so made
is lifted up with the tendo Achilhs in it, and
the oppoitumty is thus given of shortening the
tendon The joint is then freelv opened and
the cartilage remo\ed
Jfow/fs — The result ot the operation is to
iciidei a flail-like limb comparatively secure,
and to lessen the number and weight of ap-
paratus rcqmied No fear need bo entci tamed
ot difficulty in obtaining piimary union in these
paralytic limbs
CONGENITAL DISLOCATIONS
Congenital Dislocation ot the 11 ip — Etiology
— It is more common in the female than in the
male sc\, and is also hereditary The number
ot unilateral and bilateial cases is about equal.
One important factor in its production is a
biccch piesentation, and if this be combined
with a faulty acetabulnm then the head of the
femur is easily displaced at birth
PatJtoloqy — The Acetalitlum — In some cases
it is entirely wanting, while its s4e is occupied
by a convex mass of bone In other cases the
cotyloid cavity is present, but is defective It
may be found small and shallow, and about one
inch in diameter In shape it is sometimes
230
DEFORMITIES
circular, but more often triangular, owing to
non - development of the ischial part of the
Y-shaped cartilage. Its shallowness is also due
to defective development of the cotyloid rim,
especially at its postero-supenor border The
upper extremity of the femur is normal at
birth, but as age advances the head undergoes
flattening in front and above, and the neck
becomes considerably shortened and less obtuse,
and further is antevertcd or retroverted The
round ligament is occasionally thick and solid,
but more often elongated and attenuated or
even merged into the joint -capsule at the
anterior part In 83 per cent ot the cases it
is absent The capitular ligament is always
elongated, and sometimes is remarkably thick-
ened, while at other times it is seen to be
dilated and thinned Sometimes it is of a
curious hour-glass shape, and is obliterated in
its middle As to the muscles, the iho-psoas
undergoes such a change in its direction that it
finally comes to ho internal and even posteriorly
to the head of the bone The displacement of
the caput femons is usually above and posteiior,
but as the subject is more carefully studied the
number of anterior dislocations is found to be
large The symptoms are as follows — A typical
rolling gait, lordosis, prominence of the abdomen,
shortness of the lower limbs in proportion to
the general bodily development, and feeble
development of the muscles of the lowci
extremity. When the patient stands the great
trochanters are unusually prominent, and dis-
placed forwards and upwards or forwards and
backwards. The heels also aro rotated inwards
and the toes turned outwards When the
patient is placed iccumbciit, the lordosis dis-
appears and the tops of the trochanters arc not
so near the crests of the ilia as when ho is
standing The upper borders of the trochanterb
are in all cases above Nelaton's line The limb
can often bo made to " telescope " up and down
Signs which are absent aro . pain and limitation
of movement, especially m young children
Prognosis — As to the possibility of cure, the
earlier treatment is commenced the more likely
it is to be successful, and if it be begun before
the child is four years of age it probably will be
so entirely, but after that the prospect is doubt-
ful no matter what form is adopted.
Diagnosis — It is essential to make sure that
the deformity is truly congenital, t <? has arisen
from causes in utero and not to unskilful and
violent delivery. Paralytic dislocation should
also be excluded. Coxa vara is diagnosed from
congenital dislocation by the facts that in the
former the limb cannot be pulled down by
traction, and there is no flexion of the thigh and
no muscula» wasting Pseudo-hypertrophic
paralysis has often been confounded on super-
ficial observation with congenital dislocation on
account of the lordosis and waddling, but a
little care suffices to distinguish between them
Tuberculous coxitis has been confused with it,
but the pain, limitation of movement, with loss
of complete flexion, are quite sufficient for differ-
ential purposes
Treatment — The difficulties which have to be
overcome are the ill-developed acetabulum, the
alteiation in the shape of the head, of the femur,
and in the direction of the nock, the stretched
condition of the capsule, and the contraction of
the adductor muscles
Prolonged rt*t with extension has been advo-
cated by Buckminstcr Blown and William Adams,
who have published several cases, but it must
be confessed that grave doubts have arisen as
to the poimanency of the alleged cures The
time involved in ticatment is at least four years,
two of complete leeumbency and two of walking
on clutches The dis.ul vantages of this method
are evident Schede has modified this by plac-
ing the patient in the iccumbent position,
applying extension to the abducted limb and
niodci ate Literal piessuie on the trochanter
He does this for three months, and then allows
the patient to get about on the sound leg with
,in outside steel support for the affected limb.
In this support thcie is an abduction screw, by
turning which piessmc may be mode on the
trochanter This treatment is suitable only for
children under three yeai s of age Lannelongue,
in addition to the icst and reeumbency method,
has injected two 01 thieo minims of a 10 per
ecnt solution of chloride of /me with the object
of causing firm hbious growth around the head
of the fern ut
Treatment by ledwtion,, as initiated by Ptu-i
and modified by Loien/ The method is as
follows The patient is anicsthetiscd fully, and
placed on a low couch so that the suigeon can
stand w ell over him The limb is then extended
either manually or by means of pulleys until
the top of the trochanter is at or just below the
Nelaton line* If the muscles refuse to allow the
tiochanter to be drawn down they aie divided
subcutaneously The limb is now fully ab-
ducted, and by a little judicious totation the
head oi the femur may be felt to slip over the
posterior upper margin of the acetabulum, and
it sometimes moves in with a distinct click.
The difficulty now is to keep it fixed This is
best effected by placing the thigh at about 75
degiocs of abduction and using plaster of Pans.
In about three weeks the patient is allowed to
walk with the leg in this position Two or three
inches of cork -sole are added to the shoe on the
sound side, and the assistance of a ciutch or
ci utches is useful The object of keeping the
limb m this abducted position is to wedge it
firmly into or upon the acetabulum. The plaster
of Paris is renewed at the end of three months
and reapplied for a second period
Treatment by open operation The original
method of Hoffa has now been discarded, and
Loren/ has modified it But it is to be noted
DEFORMITIES
281
that when surgeons oi great opcratn e skill and
experience have endeavoured to follow in Lorenz'
footsteps they have met \vith nothing like the
success he claims Arbuthnot Lane states that
he law had good results by fixing the head close
l)ehiud the an tenor infonor spine
Other. hunt* — (Jom/euitaJJislocattonHDf almost
every other joint of the hcxly have been met
with, but they <ue meiely surgical curiosities ot
no practical inteiest
< taiiLDRAi, \M» SPINAL PARAIAHIS, DkiniiMiiihs
ARISING HIOM
The forms ot (oiebral and spinal paralysis
whieh gi\ e i ise to defoi mities <u e acute .uitci ior
polio-myelitis, ot the ceicbral .uid spinal foims ,
infantile hcraiplegia and spastic p.ual>sis ot
childhood , louomotoi ataxy and Fi lodi eu h's
disease , syi ingo-mycha , compiession paiaplogia
arising fioui canes ot the spine
Defotmttut anwiij /IWH A<ut? Anttnot /W/o-
Afyelitit t»f CeitbiaJ and Sjunal Otn/in --The
defoi unties met with in the tninh aio scoliosis,
kyphosis, and loidosis of paialytu oiiirin Of
these the most mtci csting is scohosis, and this
is oi ,111 oxtiemely intractable form, but it must
bo ticated by m.issagc, electnc ity, and supporting
appaiatus The defoi mittes of the nun ansing
from polio-myelitis aio w\eral The deltoid is
usually wasted, and theie is often a paial^tic
subluxation ot the shouldei -joint In the •• ioie-
arm" typo of juialysis of Jiemak the extensoi
muscloH aie pauilysed, while the supmatoi longus
escapes Wnst-diop then lesults Occasionally
the adduttoi muscles of the thumb aie aitected
\Vhcn the lowet ettienntH'* aio completely
paralysed they aie small, eold, and bluish, pei-
fcctly limp, and swing like a flail in all duct lions
The joints iiie so lav that the segments of the
limbs may be m.ulo to assume almost any posi-
tion. It is impoitant to astoitam in these
severe cases of paialysis of the lo\\ei limbs if
the psoas ha\e 01 have not escaped, ioi so long
as the psoas lotains power the patient <an be
made to walk with instruments after tcnotom>
and when any con ti action has been iect)hed
Paralytic subluxatums aie met with eithei in
the hip, knee, or ankle
Treatment of J'atalvttr Defonnitiet>---\i\ the
fust place eveiy effort should be m.ido fiom the
tune of onset of the paialysis to ictam the limbs
in as nearly norm<il a position as possible That
is to say, it is impoitant to anticipate the de-
formities Electrical stimulation of the muscles,
friction, and massage should be assiduously pei-
se\ered with The actno treatment of these
deformities must be of two kinds — mechanical
and opeiative The objects of mechanical treat-
ment should bo to support and protect the
paralysed limb in such a way that the muscles
shall woik to the best advantage and that the
joints are suppoitcd and controlled, also to over-
come by means of suitable apparatus deformities
which have already occurred, and to pre\ent then
recurrence The operative treatment ( onsists in
tenotomy and faKciotomy, osteotomy, arthiodesis,
and tendon-transplantation Tenotomy is useful
in ichcvmg the xanous foims of talipes of the
foot, the con ti act ion of the knees, and the flexion
of the thighs Osteotomy is not often called for
The indications foi arthiotlesis have been gi\cn
in the article of that heading (p 270), and the
indications and methods tor tcndon-tiansplanta-
tion .ire tieated under that title (p 282)
Infantile llemi/ile</ia and tijinntic J'atalyai* —
Defoi unties oi a most persistent and mti actable
nature otten ensue fiom these causes, and the
arm is moie afto< ted than the leg The position
assumed b} the aim is quite typical In this
limb flexion piedommates The shoulder is
sometimes laised and sometimes loweied The
upper arm is generally kept paiallel \vith the
trunk The foicaim is flexed at a light angle,
and is geneially in app>sition \\ith the lo\\ci part
ot the chest 01 the uppei pait oi the alidomeu
It is almost imaiiably pionated, very larely
stipulated The \\nst is stiongly flexed, and
the hand is adducted The fingers aie fninly
tonti acted The leg is in a condition of exten-
sion, and the foot tissunies a talipedic fonn,
eithc-i of equinus 01 equmo-vaius The mode of
walking is thus the heel is raised and the foot
is lifted horn the giound with difficulty, the
toes sci ape along the flooi, and latei the patient
becomes sussoi -legged in piogression The
treatment is as follows — K\eiy eftoit must be
made, li the case be seen eailv, to prevent the
onset ot deionmty by massage, manipulation,
p.issive movements ot the joints The patient
should also be taught to use the <i fleeted limbs
as much as possible, and much nnpunement
may be expected in slightei cases With refer-
ence to the use of letention appaiatus, the
outer's oxpeiif'iuo is that dnectly it is lemoved
the spasm letuins With legatd to operative
measuies in the uppei extiemit>, the wntei has
lately devised and successfully camed out an
entiiely new tot in ot opeiation It is as follows
— The tendon ot the pionatoi i.uln teies is ex-
posed and sepaiated lioin its insertion into the
ladius A gap is made m the intei osseous mcm-
biane, and the ])tonator ladn tores is earned
iound/jo*fc)(07/// to the ladius, and is reinserted
at its noi mal site It therefore becomes a
supmator instead of a pionatoi The flexor
carpi i.uhahs and other tendons at the wrist are
divided so th.it the wnst-drop is oveicomo, also
the tonti action of the fingers In the lower
extremities opeiativo measures aio fully indi-
cated For spastic talipes the tendo Achillts
should be seveied, for contracted knees the ham-
stiiugs, and in the thighs the tclfsor vagin.e
fcmoris, the sartotms, and adductors should be
divided It is astonishing tho amount of good
that lesults from this proceeding.
Lwnmotoi Atajry — This causes spinal do-
282
DEFORMITIES
fortuities very raiely Sometimes the deformity
is angular, or sometimes bcoliosis is present
In Fnedreich's disease or congenital locomotor
ataxy, scohosis develops Lite in tho disease, and
is generally soon to bo with the curve to the
right in tho doi&al legion In this disease
talipes arcuatus is also met \\ ith, and is spoken
of Liter Progiessive muscular atrophy gives
rise to a peculiar form of talipes vaius, duo to
peronoal paralysis In sj nugo-niyelia v.inous
distortions of the spine may be met with, and
many forms of con ti actions of tho limbs
ConitnnoiMiptnap/eijia is.i frequent comphc.i-
tion of spin.il canes It is raielj due to pies-
sure on the spinal cotd by bone, but moie
frequently it is caused by «i tinViculous pachy-
memngitis, the thickened membranes constnet-
nig the coid The paralysis is UHiiully bilateial
In laie cases it is umlateial ft affects the legs
generally, although the aims may suffci Litei,
01 both may be paialysed simultaneously It
OCCIIIH m about 1 in 12 to 15 spinal cases The
symptoms of compression paiaplogia are as fol-
lows — Its onset is in some cases sudden, but
more often it is giodual As to tho motoi
functions, tho patient complains of getting tired
easily, and s<x)ii the legs begin to diag and the
toes to catch in \\alking Dull aching pain is
common in the eaily stages m the body and
limbs In the bod> the most usual foim is
gndle pain or pain m the pit of the stomach
These pains are due to nutation of the nei\e
roots Oftentimes there is no antesthcsia, 01 it
occuis occasionally without motoi symptoms
The reflexes are exaggerated both superficially
and deeply The sphmcteis arc otten involved,
and incontinence of in mo and Luces occuis in
soveie cases The affected muscles waste, and
the leaction of degeneration is more ot less
marked The limbs are often cold, but some-
times peispne persistently The diagnosis is
not as a i ule difficult when the back is examined
Sometimes it happens that compiession paia-
plegia sets in befoie deformity has appeared
The prognosis of these cases is that a great
number of them show a strong tendency to
complete lecovery without opeiation Mere
recumbency with extension is often sufficient to
mduco un immediate change for the bcttei
Recurrent attacks are dangerous, but not so jwt
M Cystitis and bronchitis aio gra\e compli-
cations With regard to treatment, prolonged
recumbency with extension of the spine in the
honzont.il position often effects a smpnsing im-
provement, and should be pcrseveied with
But if, after eighteen months to two years of this
treatment, the symptoms do not improve but
rather get worse, then lammcctomy should be
resorted to* Too great results must not be
expected from lammectomy, for the operation is
as often a failure as it is a success Forcible
rectification of the deformity has relieved some
troublesome cases of paralvsis
RICKETS — DEFORMITIES OF
The skull is often enlaiged and thin, and with
it there is asso( lated hydrocephalus Tho fon-
tauellcs remain open Tho forehead is square
and the upper wall of the oibit is oblique
Theie is also a peculiar development of the Ion PI
jaw , its alveolus is somewhat inveitcd, so that
the teeth point inwaids With legaid to the
spine, tho ncket\ defonuities aie kyphosis and,
Litei, scoliosis The chest, too, is the subject of
dcfoimity, pigeon-bioast, exaggeiation of the
( urves, and subluxation of the innei end of the
claMcle Rickety defoiinit} ot tho arm is some-
times seen in seveie cases, and lx>th bones of
the foieaim may be bent mwaid or outward, or
one bono alone Tho iickety pelvis is import-
ant to obstetucians, and the conjugate diametci
is decreased o\\mg to the pioiuinenco of the
sacio-vertebial angle In consequence of the*
in w aid thiust of the head of the femur into
the acetabulum on each side, the lateral aspect
of the pehis is flattened, and the pubic arch
diminished The nckety detoi unties of the
long bones of the lowci cxtiemitv aie fully de-
scribed in the sections deal inn with defoi unties
of the knee and foot
TliM)ON-TR INsl'l, \N r \ I II )N
Ily this is meant tho reinforcement of a paia-
lysed muscle by attaching to it the tendon of «i
healthy muscle 1 1 is also know n by othei names,
.is muscle-grafting, function tiansleienee of
tendon, but the word tcndon-tiansplantatioii
sufficiently indicates the scope of the procedure
Before deciding to peiform tendon-grafting theie
aie certain points to be observed, namely —
1 The muscles should be carefully tested elcc-
tiually, and the relative strength of each ot
them detei mined, 2, all conditions due to con-
ti action of the plantar fascia, such as poscavus,
should be pi e viously icmoved by opeiation, 3,
the operation is rarely called foi when one
muscle only is partially paialjscd , 4, cases in
which all the muscles aie paralysed aie suitable
foi arthiodesis only , 5, in selecting a healthy
muscle for reinforcing a paialysed muscle it is
advisable that the one selected should l>olong to
the same group, if possible, as the paralysed one,
and the muscle selected should also be, as tar as
uuty be, in the same line as the paialysed muscle,
6, the icinforcnig tendon should bo carried as
dim tly as possible to the paialyscd muscle and
not Iniit round at an angle Tendon-transplant-
ation is particularly applicable to t'llipes cal-
caneus, as the peronei muscles and the posterior
tibial deep muscles, i e the tibiabs posticus and
the flexor longns digitorum and the flexoi longus
polbcis, are very suitable for grafting into the
tciido Achillis Cases of simple cqumus do not
as a rule call for muscle-grafting, because division
of the tendo Achillis is sufficient Cases of
paralytic valgus due to paralysis of the tibiahs
DKFORMITIES
283
anticus and postu us maj hi* treated by trans-
plantation of the extcnsoi proprius pollicis into
the tibiahs antuus and a piece of the flexor
longus digitoium tendon into the tibialis po&ti-
CUH On snmlai lines talipes vaius may be
treated. AH to the actual method of piocodurc,
the operation lequircs th.it the parts should be
absolutely aseptic The tendons to bo opeiatod
upon aie exposed, and their sheaths tieely
opened in such a \\ay that lh» tendon of the
reinfoumg muscle can be applied easily to the
paialysed muscle Taking, r t/ , the fixing of the
pcioneus longus to tlie tcndo Achilhs, the sheaths
of the peionei and of the tendo Aehilhs aie
freely opened up and a eonsideiable poition of
the pcioncus longus tendon is detached It is
then di\ ided across just above the malleoh and
passed to the under suitace of the tendo Achilhs
ncaily opposite the ankle-joint, the tendo At hillis
having been pieviously split longitudinally at
this spot The proximal end of the peroneus
longus tendon is dia\\n thiough it <md split
somewhat, and the ends attached to the posterior
surface of the tcndo Achilhs by being sewn
down with silk 01 some othei mateiial The
pinximal pait of the tendon of the leinforcing
miitu lo should be pulled quite tightly, and in-
serted at such a spot in the tendon of the
paralysed muscle that the former, when it is
fixed, is .it its utmost possible tension The
wound is then allowed to heal and the strength
of the lemioning muscles is subsequently 111-
cieased by massage and galvanism
HAND AND FIM.ERS
COVUFMTAL DKIOKMIIIEI — These compiise
clnb-hantl, conc/intta! contention of t/ie Jinyet^
supeinumnmy /inyert 01 polydactyhsm, SM/J-
prewon of the Jim/n <, wb-Jinyn* 01 syndactjl-
ism, hi/peitiophy of the Jinf/ei «, can</eniht/ trttnal
deviation nj the jingei v
ChJt-Ilantl — This is a vciy laie defoimity,
and theic aio comparatively few cases recorded
in litcratuie In most cases the child is both
premature and still-born The forms of club-
hand aie as follows, and it should be icmem-
bercd that the hand may deviate eithci to the
outer or inner bordei of the foreaim, or be in
a position of flexion 01 extension Hence wo
have radial and ulnai club-hand and palmai
and dot sal, so that tlieio are the radio-palmai,
radio - dorsal, ulnar - palmar, and ulnar - dorsal
In the palmar cases the hand forms with the
forearm a moie or less acute angle open an-
teriorly The lower end of the radius is pio-
minent posteriorly, and the caipus articulates
with the an tenor surface of the radius There
is generally some degree of mobility of the hand
on the forearm It is small and wasted owing
to the shrinkage of muscles and the absence of
some parts of the bones.
Treatment — Tho means \vhich arc adopted to
alleviate the deformity ate passive movements,
massage, the use of ictentive apparatus, teno-
tomy, and operations on the bones In any
case the result is not veiy satisfactoiy
Congenital Contnutivn of Finyet1* — This
defoimity is quite distinct from contraction oi
the palmar fascia known as Dupuytren's con-
ti action, and should not be contused with it
The affection is generally limited to the fifth
finger, but at times the ling finger and even all
the hngeiH are con ti acted It is often associ-
ated with congenital hammer-tot1, and in that
event the second toe is the one usually affected
Some i niitnu turn of the finger is frequently
met with, but it is only when it gives use to
pain and annoyance that any notice should be
taken of it In congenital contraction the fust
phalanx is usually hyper - extended, and the
second and thud arc flexed, in contradistinction
to Dupuytren's contraction, m which the fiist
ami second aie flexed and the thud is generally
extended It the defoimity is lett unrectihed,
con 1 1 action of the skin and fasci.i and of the
lateial ligaments of the mtei-phalangeal articula-
tions takes place But the contracted fascia
ne\ cr extends up into the palm as in Dupuytren's
con ti action
Treatment — In the milder decrees it is suf-
ficient to straighten the affected fingers by
frequent passi\c movements, and to maintain
the correction by the use of a small malleable
iron splint adapted to the dorsal suiface of the
hngeis This often suffices to lemove the de-
formity Should it fail to do so, the contracted
fascial bands may be divided and the finger put
up in a suitable splint Unfortunately these
cases havc> a sttoug tendency to relapse, and it
is well to wain the patient that after a fingei has
been sti .lightened a long couisc of mechanical
tie.it men t is necessary to maintain the improve-
ment Foi this purpose the apparatus similar
to that used after operation for Dupuytien's
contraction must be woin day and night for
three months
Supetnunttimy Fimfet^ — Polydactylmn —
There arc h\e varieties of polydactyhsm (1)
An additional hngei is more or less developed,
generally on the ulnai bolder of the hand, being
attached to it by a nairow pedicle (2) An
additional thumb is more or less developed
(3) A supcrnumcraiy digit more or less perfect
is closely united throughout its whole length to
another digit (4) A completely developed
extra digit is formed, and possesses its own
separate 1 unctions and tendons (5) The bi-
furcated hand which has eight fingers and no
thumbs
Treatment — In the fiist variety the additional
digit should be removed eaily in life In the
second vaiiety removal is indicated* too As to
the third variety the propriety of operation is
doubtful In the fourth variety it is advisable
not to mteifcre, and the fifth admits of no treat-
ment
284
DEFORMITIES
tiapprcuswn of the Fingers — Thebe are of
interest rather to the teratologist than to the
surgeon. If the hand is very unsightly or use-
less, amputation of it is the bobt resource, and
a good artificial hand is to he prefericd
Welled Finget^or tiymfactyhim — There tiro
three varieties (1) Two fingers, generally those
on the inner side of the hand, .ire united by
skin and fibrous tissue (2) The union is by
muscular as well as fibrous tissue and skin
(3) The bones ,iro fused throughout their
whole length, 01 rnoio often at the second and
thud phalanges only
Treatment — In the second vancty little can
be done, and the case is often best left alone
In the fust and thud vaiieties the chief diffi-
culty aftci operation is to prevent some ic
formation oi the web, especially towards the
base of the new cleft This difficulty can be
overcome cither by the foimation of a pei-
manent opening .it the bottom of the web by
transfixing it with a silver pin or by Didot's
operation, or by those operations known by the
names of Zellei and Norton Choice of opeia-
tion — (I) If th' web is small and thin, or if
the union between tho fingers is vciy close, the
formation of a peimanent opening at the base
of the web is to be piefencd The web may
be divided subsequently, and its edges tnmmcd
and sutured (2) If the web is extensive, com-
plete, and of good width, Didot's operation is
the best (3) If the web is incomplete and
reaches but halfway, Xellei s or Noitons opera-
tion is indicated
Hypertrophy of t/te Fmget* — This condition
is sometimes seen at birth in a minor degree,
and becomes exaggerated latci The hyper-
trophy may consist of gcneial overgrowth oi
all the tissues of the finger, lymphatic enlarge-
ment of the subcutaneous tissue, or a n.evoid
condition of all the soft stiuctures
Ttentment — Compression of the fingers and
ligature of the atteues have been both tned,
but without success When the finger becomes
a source oi annoyance it should be removed
Congenital and Latetal Deviation of the
Finger — This is veiy raie indeed, but is com-
parable to a condition seen in the toes It may
be treated cither by a suitable apparatus, or by
division of the lateral ligaments, or by amputa-
tion.
ACQUIRED DEFORMITIES. — Under this heading
are comprised Dupuytten't* contraction, kpnnt/
finger, and mullet Jinger
Dupuyt/en\ Contraction — Definition — A per-
manent flexion of one or more fingers aiismg
from contraction oi tho palmar fascia and its
digital prolongations
Occurrence and I&tiology — It is many times
more frequent in men than in women. As a
rule the ring and little fingers are affected,
but it may spread to other fingers In some
cases it is distinctly hereditary. The age at
which it comes on is generally in middle or in
late life — that is, when fibroid changes super-
vene Occupations seem to have some share in
its production, especially those that mvohe
repeated traumatism to the palm oi tho hand,
as in gaideners, diiveis, engiavcrs, etc In
some instances it would appear as if the con-
traction began after a definite mjuiy to the
palm — a slight wound, a sudden biuise, 01 an
excessive strain of the stiiictuics Ccitain
general conditions seem to piedispose to it, as,
for instance, gout and i hen mat ism, or the con-
tiaction appeals to be much more common in
gouty and iheumatic people, and to follow
sometimes an attack of gout Other people
have noticed it to be associated with syphilis,
and Mr William Andeison has luuaided the
opinion that it is of bactenal oiigm
Its mot bnl a unto it it/ ih as follows — The affec-
tion is pi i manly a contraction of the fasuo, and
secondly of the skin The tendons have nothing
to do with it The palmar fascia is not a well-
defined aponeuiosis, but fades oft giadually
at its edges and gives oft two sets of pioccsscs,
the supeificial to the skin and the deep to the
lateial aspect oi the fiugeis, passing to the sides
of the fust and second phalanges, ami to the
peiiosteum and to the tendon sheaths The
nature of the moibid change in the fascia is a
fibroid hypeitiophy Sometimes this appeals in
the form of small hhiomata, in others theie is
a geneial thickening of the bands, followed by
contraction (h)stuls of mate of soda have
been found in the thu kcned fas( la
tfymptom* — At fust theie is a feeling ot tight-
ness in the palm of the hand and in the ring oi
little finger, and the patient finds some difficulty
in fully extending the fingeis Latei theie
appeals nodtilai indurations with adhesions of
thu skin The lattei is first seen usually in the
tiansveise ciease of the palm The affected
fingers then begin to retract, and the hist
phalanx flexes on the metacarpal bone
Treatment — No measures except operative
aic of any avail The operative measures aie
either multiple subcutaneous division of the
contracted band as practised by Mr Adams, 01
open removal by a careful dissection of tho
palm of tho hand The method to be preferied
is tho multiple subcutaneous puncture The
operation may have to be repeated two or three
times After the operation a Uupuytrcn's splint
is worn, and the fingers are gradually straight-
ened The lesult is as a rule very good, and
relapses aie not frequent Tho writer has
performed the open method seveial times in
hospital patients, who cannot afford time to
attend ficquently, and ho has been satisfied with
tho result
Spnny Finger, known also as JetL or Snap
Finger — The description of this affection is that
if the patient closes all the fingeis on the palm,
DEFORMITIES
285
on opening thorn he finds that one remains shut,
and it can only be extended by the other hand,
and flies open like a knife-blade with a snap
Sometimes there is difficulty also in flexing the
finger, which IH accompanied by a small jerk
The affection is usually seen in the thumb, and
is due to one of two causes, either a thickening
of the tendon as it passes through its ossco-
fibrous groove, or else nari owing ot the gioove
Treatment — If the thickening can be felt it
should be cut down upon, and the thickened
portion icmoved In many cases, howexei, it
is sufficient to blister frequently and the thicken-
ing disappears, or the finger may be fixed in a
metal splint with pressuie over the spot where
the movement of the tendon is hindcied
Mai It t Finytft — This is also known us "drop
finger," and is due to subcutaneous iiiptine
of the extensoi tendon whcie it is inserted into
the last phalanx Tt«» usual cause is a fall for-
wards on the fully extended fingers, with the
lesult that the nines of the extensor tendon
aic torn «iway and the finger cannot then be
fully extended "NA ith icgaid to tieatment, the
finger may bo placed in a malleable non splint,
with the List phalanx h\ pel -extended , 01 an
incision should be m.ule ovei the dorsum ot the
last ph.ilanx, and the tendon xciiiiitcd to the bone
HALLUX \ AU.US (IJtMUN)
Tt is laigely due to the useot impioper boots,
not uecessanly of tight ones, but of those wliuh
.ne pointed and often too shoit In some cases
it is due to osteo-aithiitis and gout The de-
formity is a displacement ot the great toe
outward, with piomincme of the base of the
pioximal phalanx and oi the head of the first
mctataisal bonp, mostly of the lattei Both
these poitions of bone are often enlarged and
coveied by a bunion 01 buisa The bony swell-
ing is especially noticeable in cases of osteo-
,u tin i tin The anatomy of the affection is a
partial suhluxation ot the first phalanx out-
wards from the head of the fiist metatais.il
bone, lea\mg it exposed to piessure The liga-
ments on the innei side of the joint are stretched,
and occasionally perforated , those on the outci
side are shortened Of the tendons the extensoi
propnus polhcis is displaced outwards The
formation of the false bursa 01 bunion is second-
ary to the enlargement of the bone The bunion
is very liable to inflammation, and suppuration
may cause ccllulitis with occasional disorganisa-
tion of the joint Sometimes the bunion has a
corn on it The symptoms ai e sufficiently plain,
but the affection varies in degree, and there is
no doubt that women suffer more frequently
than men
Treatment — Prophylactic Pointed boots
must be absolutely forbidden, and the inner
edges of the boot should bo quite straight In
slight cases curative treatment consists in wear-
ing pioper boots, with the application of cold
and soothing lotions to the inflamed and tint k-
oned skin, and the wealing of the digitated or
divided socks Some ad\isc the use of a post
between the first and second toes in the boot,
but this does not answei well in practice In
othci cases a bunion spung is used, but if the
deformity is at all severe and the buisa huge
and painful, the only course is operation It is
not sufficient meiely to chisel away the piomi-
ncnt poition of bone, but the opoiatioti jmr
"tcrtlence foi these cases is excision of the head
of the metatarsal bone With this operation
the w liter has ample reason to be satisfied
I/all VJT I'lnmot Pupon-Tor is the i e verse ot
hallux \algus, but is not associated with pain
in the same way If it is excessive the treat-
ment < oimists in manipulation and the use of a
light splint to pi ess the toe* outwaids
Hallnr Rifjtdus is a somewhat cunous affec-
tion The gieat toe cannot be extended beyond
the straight line, and any attempt to do so pro
duccs sevei e pain The tendon of the extensor
propnus polhcis is alwa)s tense With legard
to the pathology of this affection opinions differ,
but the writei has been able to ascertain that it
is ficquently associated with osteo-arthritis and
with inflammation of the synowal fringe be-
tween the sesamoid bones The mechanism of
the aftec lion is easy to understand When an
attempt is made to extend the toe, the head ot
the metat.irsal bone and the base ol the first
phalanx pi ess upon this inflamed spot so that
the ngidity of the toe is really reflex Local
measuics avul but little, and in cases which are
at all maiked it is always best to excise the
head of the hist mctatarsal bone, and to remove
a small poition of the pi eminent pait of the
base of the hist phalanx
HAMMFU TOR
Definition — Adefoimity usually affecting the
second toe, and consisting of dorsi-flexion of the
first phalanx, plantai -flexion of the second, and
extension of the thud
Etwlot/y — In some cases it is congenital, and
is assix lated w ith congenital contraction of the
little fingei In other cases it is distinctly
hereditaiy But it is sometimes due to acquired
causes The chief of these is the use of short
boots The appearances presented aie as follows
On the dorsal aspect of the hist mterphalaugeal
joint a painful corn is frequently present, be-
neath this is a buisa which from tune to time
inflames and suppuiates On the under surface
the skin is contracted, and at the bottom of the/
groove the long flexor tendon can be felt. The
first phalanx is in a state of ex ti erne dorsi-flexion,
so that the head of the mctatarsal bone is un-
covered below to about half its dxtent. The
anatomy of the part is as follows In the first
place there occurs conti action of the extensor
tendon This is followed by contraction of the
flexor tendon, and with giadual shortening of
DEFORMITIES
the lateral ligaments The latter point is most
important to recognise, as upon it depends
successful treatment
Treatment — In slight cases attention to the
boots, together \\ith manipulations and the use
of the malleable iron splint at night, will remedy
the trouble But in many cases it is necessary
to operate, and the writer would dcciy amputa-
tion of the toe, AS it is qmto possible to remedy
the trouble without this lather severe proccduie
If the toe be amputated, then bunion almost
inevitably follows, because the hi st toe is readily
displaced outwards The ope Kit ion consists m
subcutaneous section of the JIcxoi tendon and of
the lateial ligaments from the undei suiface of
the hist mtcrphalangeal joint, and often of the
extensor tendon on the doisum A I tei the opera-
tion the too is fixed to a malleable non splint
until the small wound is healed, and it is then
gradually extended (Jood hioad boots should
be ordered for use aftcrwaids
TOES — DEFOKMITIES OP
The othci affections which aie met \uth m
the toes ate Afyjtdfzcty/ffr/i, 2'nlydtwtyhtm, »Sto/i-
presiwn of the Tuei, and Late) a/ De nation of f/n
Toes The latter is the lesult of bad boots, and
may be icmcdied by mampul.ition, the wearing
of a digitated sock, 01 by the use of a sole-plate
with slots in it In modciately scveie cases the
lateial ligaments may be divided, and in extreme
cases amputation is necessary Hypeitiophy of
the toes, gcncially of the hist toe, is scon fiom
time to time The hypeitrophicd toe is fie-
qucntly displaced inwaids 01 outwatds It may
attain an immense size In most cases paitial
or complete amputation is lequned eventually
The ticatment of syndactyhsm in the toes is
the same as that of the hngcis, although it may
be better to amputate at once
( 'LUli-Pnor — ( JOMIKKITAL
Etiology — The causation of congenital club-
foot is still doubtful, although much light has
been thio\vn upon it by the labouis of R W
Parkei The matter may be discussed undei
four headings (a) ai tested development of the
bones of the leg , (Z») causes ansing fiom nei\e
lesions, (() mechanical causes due to malposi-
tion ot the foetus in uleto , (</) abnormal develop-
ment of the bones of the foot (a) In describing
bow-legs it is stated that ceitam forms of con-
genital bow -legs are accompanied by talipes
equmo-vaius Again, some cases of varus and
oqumo \artis exhibit congenital absence of the
tibia But these congenital abnormalities aic
found m only a few of the cases of equmo-varun,
And cannot be the sole cause (f>) Nerve lesions
In some cast* menmgocele, encephalocele, hydro-
ccphalus, and spina bifida coexist with congenital
club-foot, but these are very few in proportion,
so that the nerve theory fails to explain the
majority of the cases It has been held by some
that the deformity is due to partial asphyxia at
bnth, icsultmg in convulsions, but in the absence
of definite examples, carefully collected and im-
paitially examined, this opinion cannot l>c
advocated (<) Mechanical causes duo to mal-
position or compression of f fletus in utet o There
is ample evidence to show that this is the prob-
able explanation, and fiom the figures given by
Paikor m his «oik it is easy to undei stand that
owing to intra- utei me packing the foot may
duimg fojtal life bo lotamed in one position
which becomes fixed As a iiilo the position w
such as to lead to some small degieo of equino-
\aius, even m presumably normal infants, and
they subsequently lose this tendency to cveision
when they commence to walk. If the position
ih more decided, then an abnoi nial condition of
the loot anses — cithoi equmo-vai us in both tect,
01 cqumo-NaiiLs in one and equinox algus in the
othei, or ( alcaneus in both The most common
modes of pioduction are by accidental locking
of the paits, by locking of the parts due to
ahnoimal positions of the limbs, by exceptional
positions of the limbs, independently of locking,
and by congenital absence ot ceitam bones (The
last supposed cause (tf), abnonnal development
of the Ixiiifs of the foot, cannot clearly be estab-
lished , one can only say that the normal
inversion of the lowei limbs tn uteto peisists
some time aftei bnth The. reason of the
persistence is piobably close intra-utei mo pack-
ing, and this thiows us back upon Paikei's
obs»ei vations
Fount of Conyenital (Hun-Forti — Varieties —
The most common form is TALIPES LCJUINO-VAKUS
Some autbois state that talipes vaius is more
common, but if a caieful '^animation be made
of a laige numbci of cases it will IK» found that
most of the so-called varus-c«iscn ha\e some
shortening ot the tendo Achilhs and laisuig of
the heel, so that teally they aie cases of cquino-
vaius And this point is pi OAK! by treatment,
foi until the tendo Achilhs is divided, the foot
cannot be fully i ectihed The next most common
form is talcaneo-valgiis, while the puie calcaneus
and puic equinus aie rare, the List-named in-
finitely so In the consideiation of congenital
club-foot, theiefoie, talipes equmo-varuH will be
described fully
AjijwaHincei — The nature ot the deformity
is as follows — The heel is laised and the foot is
extended , that is, it is in a position ot plantar
flexion The sole of the foot and the toes tuo
add noted and brought to the middle lino mstc.id
of being directed to the front. The mteinal
bolder of the foot is raised to a varying degree
and bent upon itself, so that it is concave With
this the adduction of the gicat toe is often very
marked The external border of the foot is
convex, and is in contact with the ground and
foirns the main point of suppoit in progression.
The deformity is situated in two places m the
foot chiefly m the neighbourhood of the mcdio-
DEFORMITIES
287
tarsal joint, and to a less degree at the taiso-
metatarbdl and phalangcal articulations and at
the ankle J)ue recognition of the sites of
deformity is essential to pioper treatment , foi
the back pait of the toot, that is behind
the medio-tarsa! joint, must serve as a fixed point
foi the eoriecUon of the fiont pait , and fixation
oi the back pait can only be obtained by IcaMiig
the tendo Achilla intact until the front part is
restored Congenital club-foot is moie frequent
in boys than in girls, and occuis about once in
one thousand bnths Double congenital valgus
is moie usual than single Voiy frequently
\vith club-foot of congenital oiigin, mcmngocclc,
spina bihda, paitial or complete, .imputation of
the limbs, absence of the fingers, polydactvlism,
byndactylism, and absence ot the bones of the
leg 01 foot aio found to coexist
Deytees — The deformity v.^iics according to
age FIRST DEGREE — The foot <au be moment-
ai ily i eplaeed by manual foi c e SKCON D DEC, HEK
— The ioot (annotbe i eplaeed manually On
attempting foicible leposition theie remains
some «idduetion 01 extension of the foot, .ind the
sole cannot be planted squaiely on the giound,
.ind the gicat toe is much separated fiom the
second TIUHD DEO REE — Seen in clnldien and
adults, the ioot is in a iigid and resistant state
with aggravation of the dtfoimity and stiong
oontiaction of the soft paits Fouiuir DECJKEE
—The defoimity is mveteiate 'ind ol old stand-
ing, and much malposition of the bones is picscnt
with the thickening of the soit tissues, and foi-
mation of false buiscU on the outer side of the
foot ovei the bony piominenees The foot may
be so much distoited that the patient walks on
the dorsum, and the sole of the ioot looks
upward** and back\\aids
MonniD AN A'icnn — Authois aie agieed that in
talipes equmo-vai us thoie eusts extension of the
astragalus upon theleg.it the ankle-joint with
twisting downwaids and mwaids of its head and
neck, and in w aid subluxation of the scaphoid,
elevation of the tubeiosities of the os calcis, and
rotation oi the same bone aiound its veitual
axis The bones aie modelled fust of all in
eaitilagc, and so long as they remain imossihed
they may still be moulded to a normal shape
and no extensi\e opeiation is needed Without
discussing the mmutitO of the moibid anatomy
of club-foot it is necessary to remaik that the
angle of the neck of the astiagalus is increased
from thirty-eight to about fiity degrees An
astragalus taken from an adult case of club-foot
presents several new features Its body is no
longer squat e but trapc/oid, and even tuangulai,
and the head piotiudcs from the fiont of the
ankle-joint The scaphoid is found to be much
atrophied, and its tubercle has very ueaily dis-
appeared. On the anterior aspect of the internal
malleolus is a new facet foi articulation with the
scaphoid The ligaments on the dorsum and
external border of the foot are elongated, and
those in the sole and on the internal hoidei aio
contracted The plantar fascia is also contracted
The tendons at fault are the tendo Aihillis,
tibialiH anticus and posticus, extensor proprius
polhcis, the flcx.eu longus digitoi urn, and the flexor
longus polhcis Other soniew hat remote lesions
aie met with associated with congenital club-foot
One interesting lesion is genu leeur \atum with
absence oi the patella, another is scoliosis
Tlu. Obstadev to Betlutftvn in Congenital
Talijtes fit/uino-Vai us arise (1) in the infant,
f lorn the altered diiection of the neck of the
astiagahis, the contracted antenoi fasciculus of
the internal lateral ligament, the eon ti acted
iistrigalo- scaphoid and calcaneo- scaphoid liga-
ments , (2) in the adult, from the profound
aiteiadon in the. shape of the bones, fiom the
ioiiiiation of new joints, fiom fixation of the
ligaments and tendons in then abnormal attach-
ments and eouise
JJKMfn<m*> — The points in any given case on
which inloimation will be sought aie the follow-
ing (n) Tan a pel feet foot be obtained' (/>)
Will .1 shapely foot result from treatment I
(() Will the patient be able to walk comfortably
and lapidly? (d) What possibility is there of
i elapse, and, if i elapse occur, can the foot again
be rectified? (e) The dmation of tieatmcnU
The answei to question (a) depends upon the
age at which ticatmcnt is begun and the degice
ot defoimity Many cases of congenital varus
of the hist and second degrees aie cmed if
treatment is begun befoie walking is attempted
lAiscs of the thud degiee, especially after weight
has been bome on the dcfoimed feet, seldom
gi\e poiiect lesults In any e\ent, peisistency
in ticatmcnt is essential, and it is the duty of
the suigeon to insist that i elapse is a likely event
so long as giowth is going on, and eveiy care
must be taken to pie vent it (6) A shapely foot
will often lesult iioni early and continued tieat-
ment, but in some instances there will always
i emam a squuc-tocd appeal ance and the foot is
ungainly (<) The question of comfoi table
w. ilkmg depends upon the absence of cicatricial
mateiial aftei tieatmcnt Tarscctomies and
such like piocedurcs should theieioic be avoided
if possible (d) As to the possibility of relapse,
there is o\ery likelihood of it in congenital cases
unless peisistent care is cxeicwed all thiough
childhood and adolescence, but lelapsed vaius is
capable of much improvement by the methods
to be detailed subsequently (e) The duration
of time lequned foi tieatment depends on the
degiee of deformity and the method adopted
The slowei oithopcedic methods are effectual
but tedious A deformity of moderate severity
can be i educed by manipulation and wrenching
m two to three months j
jDia(/nous — Some difhculty will arise m dis-
tinguishing in a child congenital and paralytic
eqinno-\aruR, but the mam points are, that m
paralytic equmo-varus the limb is wasted, cold,
288
DEFORMITIES
and blue, and the elcctncal i factions aie entirely
lost m tho affected muscles. From spastic
paralysis the diagnosis of congenital cqumo-vaius
is more difficult The piesence of rigidity of
the knees, adduction of the thighs, flexion of the
forearm and tonti action of the hand, aie pointb
sufficiently distinctive of spastic paialysis The
hystencal foim of equmo-vaius readily disappeais
under an anaesthetic
Treatment — Of slight cases or wises o* IHK
Fiitsr PEORER — Tho feet in this dcgieo tun
bo brought to a stiaight line with the legs by
manipulation, and sometimes cveited But when
the pressmc is relaxed they spimg back to then
original position Also they cannot be fully
dorsi-flexed when they aie stiaightened and
everted. Such cases can be treated by manipu-
lation alone or by manipulation combined with
massage and letention apparatus In manipu-
lation the movements to be practised aie
abduction and eversion at the tranm crse tarsal
and sub-astragaloid joints, and flexion and ex-
tension of the whole foot of the ankle finishing
up with circumduction. The movements should
be easy and gradual, and should last about fixe
to ten minutes three times a da} Manipulation
can be combined with letention appaiatus in the
following way A straight noil-padded piece of
soft iron is bent to tho shape oi the deloimod
foot and applied to the outer bordci of the limb
Gradually the angle of the splint is diminished
until the foot can be fixed in a straight line with
the leg without pain This snlhces to remove
the vaius The equinus can be ovcicome by
tho use of a tin shoe with a quad i ant movement
at the ankle In place of the splints many
surgeons piefer to use plastei of Pans fiequently
changed, additional rectification being obtained
whenever a fiesh plaster of Vans splint is put
on ; this should be at least evciy thud day
OF TIIK SECOND DEGRKE —Here the foot can
neither bo fully e\ cited nor brought into a
straight line with the leg in attempting to do
so the tendons of the tibiahs anticns and postieus
and tho flexoi longus polhcis, together with the
tcndo Achilhs, become tense Cases of this
degree may bo cured by (a) tenotomy with the
after-use of shoes and apparatus, or (b) tenotomy
followed by wrenching on two or three occasions
and putting tho foot in plaster of Paris after
each partial correction As this degree is
usually found in children under four years of
age, the bones and ligaments are still elastic,
and it is not necessary to icsoit to deep opeia-
tions such as Pholps* operation or the various
kinds of taiscctomy The following tendons
need division In tho nrst stage, the tibiahs
anticus and postieus, the plantar fascia and the
anterior fase culus of the internal lateral liga-
ment of the ankle As to whether reposition of
the front part of the foot should be aimed at im-
mediately after tenotomy or gradually is a matter
of eomcwhat diverse opinion As a rule gradual
reposition by means of the flexible iron splint is
to bo preferred, and tho vaius will be giadually
overcome until tho foot is in a stiaight line with
the leg Then and only then should the tendo
Achilhs be divided to reduce the equmus Alter
the tendo Achilhs has been divided an Adam's
varus splint, or a tin shoo with a quadrant at
the ankle, is substituted foi the flexible iron
splint As in the first degieo, some suigeons
prcier to use plaster of I'aris instead ot splints
or shoos , but its disadvantages aie th.it its use
invohes a good deal ot ttouble if it is renewed
sufficiently frequently, and the foot cannot be*
manipulated while it is on This is a very
essential pait of the pioceedings. After-treat-
ment, extending ovci some yeais, by means of
walking appaiatus, is required In some of these
cases theie is very consuleiable inversion of tho
whole limb This may sometimes be ovcicome
by irequent twisting movements on the part ot
the attendant 01 by linear osteotomy
Or TIFF. THIRD DIM, RLE — Higid 01 resistant
club foot Ileic all the deformities are ex-
aggeiatcd and the bony piommcnces are well
marked on tho outer side ot the foot and aie the
sites of considerable pain The host foim of
tieatment foi these rigid feet is, in tho wiitci'*
opinion, a gradual one Theio is no com so that
answeis so well as tho following Take the
patient off his feet foi two or tluce weeks and
gn e him < omplete rest , by so doing the painful
spasm of the muscles passes away and the foot
soon but ornes less rigid The degree of supple-
ness which returns to the foot is suipiising
Tenotomy of the tibial tendons and plantai fascia
is now pei formed, and tho variw is ovcicome by
using a mall cable 11011 splint 01 by employing a
Scarpa's shoe Happilv successful as tieatment
on these lines is, the length of time occupied
has induced sui goons to devise* other means of
ovei coming tho difficulties and lestonng the
foot A \ aluable adjunct to treatment is foi cible
rectification or wrenching The best appaiatus
is Thomas' wrench It is bettci in obstinate
cases to employ it frequently and modciately
than with violence The more extensive opera-
tive measures aie free subcutaneous division of
all tho resistant structuics at one sitting, Phelps'
operation, tarsal osteotomy and tarsectomy As
to tho value of either of these operative pro-
cedures it is well to remark that Phclps' opcia-
tion or treatment by open incision has been
for some time on its tiial and has not given
satisfaction Free subcutaneous section is fol-
lowed by so much seaming that the loot remains
i igid although it may be of a good shape Tarsal
osteotomy is often insufficient because it is
difficult so to plan the incisions as to allow of
the bones being placed in their proper axes Of
the many forms of tarsectomy it may be said
that removal of the astragalus is the best.
Now, m commencing the treatment of a case,
either in this degree or the next, it is important
DEFORMITIES
289
to decide at once if the foot is capable of ic-
poHition by the giadual method, or lequnes
tarsectomy If the lattei mcasuie IN tailed for,
the writei has no hesitation in pioiiouiicmg
astragalcctomy to be the opeiation \\liuh is
likely to yield excellent results on the following
pounds — the icsultmg good mm cutout of the
ankle, the immediate ,ind peimanent collection
of the defonmty, the absence of leouiionce, and
the ease of the opeiation As to w edge-shaped
tarseotonnes, the opeiation is easy, and it is xoty
tempting, if a foot is too shoit on the innei side
and too long on the outoi, to saw out a piece oi
Ixme and put the foot sttaight But this docs
not appe.u to be a xery scientific pioceeding
The cause of the tumble is in the innei segment
of the longitudinal aicli, and theie the deformity
should be lectificd
Or ins FOUR i ii DKUIU.B — Heie the distortion
is exaggeiatcd to its utmost limit and the toot
is fixed, feeling as if it weie set in plastei of Pal is
The decision h.is to be made as to between .istia-
galectomy \\ith fiee division of the icsistmg
soft stiuctiues and ampuUtion The lattei is
veiy laiely called foi, and many patients no on
hobblmo about \\ith ulceiated feet
Timtment <*t rehijtvd «ms .110 best conducted
on the lines ,ul\o<ated foi the second and thud
dcgiees .is abo\e
Oongfint.il talipes (alcauens is seldom \eiy
lesistant to tieatment, and the same may be
said of « alcaneo-xalgus It is necessaiy to
divide the cont lotted tendons and use the
malleable lion splint foi leposition, suitable
manipulation* being tamed out twice daily
CLUB Foor — At guiUH)
Clu^f-ffttif ncif tu ted — ( Vir/v& — The most usual
<;ause is infantile |)aialysis, and less frequently
spastic paialysis Haiei causes aie cH.itnccs
such as icsult fiom bums , tiaumatism, Mich as
injiuies to bones and fractures, sexeiancc of
tendons and nei ves , inflammation, such as
occuis in acute osteomyelitis when the late of
growth of one bone is attested, xvlule in the
othei it is notm.il, "talipes dccubitus," a spuii-
ous fotm of talipes due to conti action oi the
tendo Achillis, and occurring in bed-ndden
patients, and lastly hystencal talipes
Taltpei Ef/umui — The most common cause is
spastic paiaiysis, less frequently infantile pata-
lysis The degices oi talipes equmus aie as
follows —
THE FIRST DFGHKE or i ight-angled contraction
of the tondo \chilhs — When the kiieo is fully
extended the heel cannot be biought into com-
plete apposition with the ground \uthont pain
or force The results of tins slight deformity
are foimation of corns beneath the heads of the
inctatarsal bones, slight lameness and shoitenmg
of the a tilde, and some inversion or cveisiou of
the foot at the ankle Many cases of so-called
talipes varub or valgus are found to be cqinnus
when caietully examined with the knee iully
extended
TUB SECOND DEGREE — The heel is taised well
oft the giound and piogression takes place on
the head of the mctataisal bones, beneath which
coi us are found The plantar fascia is frequently
conti acted in this degioc*
THE Tin ni> DEC.REE is ftn cxaggotated condi-
tion of the second, and the foot is bent completely
back \\auls The moibid changes in the bones
are such as would be expected from the more 01
less vertical position assumed by the toot The
plan tin fascia and ligaments and postctioi liga-
ment of the ankle ai e conti acted So too are
the tendo Achilhs, the long flexors, and the
puioi ions longus Inpnialytit feet the extensors
.ire fatt v and degenerated
The diagnosis is simple \\hen the affection is
well marked and oi the second and thud degrees,
but in the fust dcgtee oj i ight-angled contrac-
tion of the lendo Achilhs the affection is often
oxeilooked Talipes aicuatus and plantaris
(pes cavus) aie often due to paiaiysis of the
inteiossci with some \\eakntss of the long ex-
tensoi tendons
TitEATMfcvr OF TALIPES ECJUINUS -In case of
the fust degiee 01 light -angled eonti action,
manipulation and active and passixc exercises
designed to stieUh the tendo Achilhs may be
employed A toe-ele>atmg spimg attached to
an outside \eitical steel suppott is useful Hut
much time and tiouble may frequently be saved
by drudmg the tendo Achillis, taking caie, how-
evei, that the tendon does not become too long
The doi si -flexion should be controlled by a
" stop " at the ankle In equmus of the second
degiee, section of the plantai fascia is tailed for,
and when the sole of the toot is unfolded the
tendo Achilhs is divided If the toes should be
cl.uved, the evtensoi tendons may be divided
opposite the heads of the metalaisal bones, at
the same time that the plantai fascia is divided
Immediate aftei -treatment consists m the use of
Scai pa's shoe 01 plastei of Pans , and to prevent
the tendo Achilhs becoming too long the ankle
should be conti oiled by a " stop " Cireat atten-
tion must be paid to massage1 and the application
of the induced cut tent m paialytic cases In
the thud degiee the front pait of the foot should
be unfolded and the tcudo Achilhs divided sub-
sequently The \N tench may be treely employed
if the deformity is obstinate Should it fail,
astragalec tomy is called for In spastic cases
the conti acted tendo Achilhs should always be
dnidcd, despite the adMce sometimes given to
the conti My By doing so, much lameness w
a\oided and the patient walks in comfort
Acquired tnlijw cal«tn<n<* is the tesult either
of infantile paralysis or is due tJ excessive
lengthening of the tendo Achilhs after an
operation for talipes equmus It is a very
troublesome defonmty to treat. Its aspect is
eiitnely different from that of the congenital
19
290
DEFORMITIES
calcaneus In the acquired form the heel is
dropped and forms a >eiy distinct pi eminence,
and the aich of the foot is much inci eased, and
there is Home contraction of the plantar fast id
lu all caHOS wheie the heel is much dropped and
the arch ot the foot unduh concave, especially
if contraction of tin- plantar strut-tines have
ensued, the outlook is bud The chief difficulty
consists in keeping the heel up, and this is
especially BO when the cause is infantile
paralysis
Treatment. — Mechanically, a boot may he used
having an outside steel support with a toc-
depressmg spimg Of eouisc a conti acted
Slantar fascia should picuously haxe been
mded Fioin an operatnc point of view
many attempts have been made to shoiten the
tendo Achillis, but these as a lule ate not
successful because the tendon is extiemely thin
The best Jesuits in the tieatment of acquncd
calcaneus .110 obtained fiom tendon tiansplanta-
tion (fi v )
7Vffyvs Kttftineo-iwff/ii'i ami rufacnm-iw us arc
usually due to infantile paralysis In calcaneo-
valgns the heel is depiessed and the loot is
tinned outwards, while in calcanco-vaius the
foot is turned inwards Sufficient indications
for treatment aic given undei the headings of
varus, valgus, and calcaneus
Talipes Arciiatus and Plantarn ot Pe* Cam*
— In these deformities there is increased con-
cavity of the arch with a coiiespondnig dot sal
convexity In talipes arcuatus the arch is
increased, but the heel and the balls of the toes
arc in a horizontal plane If the balls of the
toes fall below the level of the heel, and the
arch is at the same time increased, then the
condition known as talipes plan tans is piescnt
The causes aic slight paialysis of the antcnoi
muscles of the leg following dentition, measles,
scarlet fe\ei, chorea, infantile paralysis They
arc also associated with Fnedieich's disease, and
some say (e tj Duchcnne) that they are due to
paralysis of the intciossci and lumbricales The
most frequent symptoms aic pain in walking,
increase of the arch of the foot, and coins beneath
the heads of the mctatarsal bones Treatment
consists in division of the plantar fascia and the
after-use of a Scarpa's shoe with a single uplift-
ing movement in the sole
Tahpfx Vaius — The acquned form is usually
due to infantile paralysis and to one variety of
progressive muscular atrophy in which the
pcronci muscles are the earliest to be affected
With regard to the appearances and treatment
of a varoid foot they are sufficiently detailed in
the description given of congenital talipes equino-
varus.
Talipes \ialqw (acquired) anses either from
infantile paralysis, spastic paralysis, rickets, or
as a sequel to Potts' fracture The appearances
in treatment are precisely similar to that of
ordinary flat-foot
FLAT-FOOT
(SPURIOUS TALIPES ^ALau8)
Definition — Flat-foot is a defonmty of the
feet, often painful, eharactciised b\ abduction
and e version of the toot with loss of the aich
Weak ankles or xalgus ankles Weakly
children, especially those suffcimg from rickets,
frequently tui n their feet ovci in \\ alking, and
associated \tith this condition, which is due to
relaxed ligaments, theie is some genu \alguin
(retina! Description mid Appeaumce of Flnt-
t<x>t - -All the changes of the foot aie due to
sinking ot the so-called aich, not only in the
longitudinal but also in the tiansverse direction.
The depression downwaids and inwaids of the
head of the astragalus and the outward twist of
the anterioi pait with extreme lotation oi the
loot arc the immediate results The foot is m-
ci eased in length on the inner side and it is
In oadoned Flattening of the sole is also pi csent,
and the instep loses its loundness The inner
bolder is com ex instead of concaxe, and is nt
contact with the giound It is also thicker
than noimal The heel appeals to be shoitencd,
the internal malleolns be< omes extremely pionu-
nent in seveie cases and descends downwaids,
inwards, and backwaids, so that its tip is either
in a line with or even behind that of the external
mallcolus On the inner aspect of the medio-
taisal joint the head of the astiagalus is
piomincnt It sinks downwaids, forw.uds, and
inwards, and the scaphoid becomes unduly
pi eminent The soft tissues ovei the astiagalus
and scaphoid aic olten hyperti opined, and false
hursie and thickened epideimis may be seen at
these spots In fiout of the iiuxlio-tai sol joint
the iniici border is sloped outwaids, and the
great toe is frequently xalgoid The outei
Ixmier is common)} shoitened and often laised
fiom the giound In many cases \ancose veins
and sweating of the feet coexist , so that it is
probable that flat-foot arises fiom defective
mncivation of the \essels of the legs and feet
In exccption.il cases wasting of the tibiahs
anticus is seen
Deyteei of ttie Mat-foot — For purposes of
description there may be said to be four degrees
First degree or oncoming flat-foot — There is
noticeable some sinking of the arch when the
patient stands and he is told to bear the weight
fully on the foot This sinking disappears on
adduction of the foot, standing on tiptoe, and
on sitting Pain is frequently present at this
stage Second degree or pronounced flat-foot
— The arch has sunk to some considerable
extent although the head of the astragalus is
not touching the ground The deformity cannot
be reduced by any effort of the patient, nor can
the feet be voluntarily inverted The pcrone
tendons and the extensor commums digitorum
are seen in relief, and there is considerable
muscular spasm and pain. Third degree 01
DEFORMITIES
291
spasmodic flat-foot — The astragal us and scaphoid
arc touching the giouud , the foot is \eiy
tender, and the patient can only hobble, and
the deformity cannot be reduced eithci by the
patient or by the smgcon The peionei and
extensoi conununis digitomm tendons .tie in
strong relief, and the thickening of the soft
tissues 011 the inner Hide is much in evidence
Fourth degiee or osseous flat-foot — In thin
degree the defoimity is excessne, and inaikcd
changes oecuiung horn arthritic are met with !
At the mediotcUs.il .ind other joints In some- I
cases it is said ankylosis takes place
T/ie Etwlfufy and Cauvittou of Flat-font — In
the majouty of cases there are three factors
mvoh ed, — adolesc ence, feeble health, and strain
on the feet out of pioportion to the musculai
development Under the heading of feeble or
impaned health contributing causes are, weak-
ness following exanthemata, acute iheumatism,
and amemia Excessive strain on the foot
frequently arises fioin occupations imolving
long standing on weak feet (static flat-foot)
In addition to these geneial factors, local condi-
tions ,ui' concerned -foi example, bunions and I
corns on the outer side of the foot, hallux valgus,
genii valgmn, shoitness of one limb, high-heeled
and iitiiiow faints, gout, «md injury
Pntftftloffi/ and ^i/mjttom^ — Abduction of the
foot is the position of weakness, and adduction
of strength find aitmty , foi the usefulness of
the ioot vanes \\ith the preponderance of power
of the adductoi muscles When this is lost
weakness and (irini ensue In fact, flat- ioot
depends upon simultaneous relaxation of muscles
and ligaments, piobablvdue to \asculai changes
The most maikinl change is m the mfeiior cal-
caneo - scaphoid <uid the cakanco-astragaloid
ligaments As the ankle IMM nines more valgoid
its ligaments suflei m piopoition The nupci-
ncial part of the internal lateral ligament is
elongated and thinned , the plantar fascia gnes
way, the muscles ot the calf waste, ami the ealf
loses its roundness, tho peronei are in a state
of tension and often stand out like cords The
alterations in the position of the bones can be
readily understood if one giasps the fact that
in flat -foot the astragalus descends, and the
bones in front of the medio-tarsal joint are
twisted on their axes, so that the mnei bordei
of the foot is hi ought downwards and inwards
In many cases pain is piesent from the first,
occasionally it is felt only aftei a twist 01 sprain
of the font It commences as a feeling of fatigue
succeeded b\ dull aching This aching becomes
more acute, and later assumes a sharp and intense
form. The tender points in the flat-foot are
well defined They are found beneath tho head
of the astragalus and tubcro&ity of the scaphoid,
also below and in front of the internal malleolus,
on the dorsum of tho foot, and about the
bases of tho first and fifth metatarsal Ixmcs The
causation of the pain is first of all stretching of
the muscles, ligaments, and fascine, and the
acute pain is probably referable to surfaces of
bone not normally m contact being brought into
iclationship to one another at points which are
not accustomed to pressure Swelling of the
feet and local pufnness arc frequently seen over
the tcndei points, and redness from time to
time dependent in a degree 011 tho amount of
standing and walking The existence of flatten-
ing of tlie sole is best ascertained by taking a
tiacmg 01 outline of the "tread" Alteration
in the gait In cases of some severity the gait is
liinibpimg and awkward , the patient is splay-
footed , the foot is no longer elastic*, and walk ing
is f uither mif>edcd by the attendant pain In
fact the patient is wooden-footed Loss of shape
in the feet is fully described under the sub-head-
ing ot appearances Sweating of the feet is also
mentioned above, and a probable explanation
hah been given Flat-feet do not become cured
without treatment As a inle the pain and
disability become steadily woisc, and tho patient
has to seek lehef fiom the inconvenience
Diof/no^ts — Probably theie is no defoimity so
easily and so often overlooked as slight acquired
valgus The best method of detecting the
tiouble is to take a tiacmg of the sole of the
foot The writer has known flat -toot to be
treated foi iheumatism, gout, and foi ostitis of
the bones of the taisus
Titfc \iMhvr — Genet al — If amvmiabc piesent,
iron should be given for a considerable penod
When the ihcumatic taint exists, salicylate of
soda in subacutc ta.ses, and in chiomc, iodide of
potassium and tincture of guaiacum, will be
found servu cable (JonoirhoMl iheumatism is
vcr\ intractable In laclntic flat-foot cod-liver
oil, phosphate of iron, plenty of fresh milk and
pmc an, will go far to effect a cine The relief
of pain is often a pressing necessity The suiest
therapeutic measure is rest, entue and absolute
Local T teat merit — The mcasuies we have at
our command are rest, exercises passive and
active, mechanical suppoit, and operation As
to the ticatment of the first and second degrees
— In static and rickety cases the first essential
is absolute rest, and with this may be combined
eversion of the foot The patient should be
told to sit on a comfoi table sofa 01 bed "tailor-
fashion "
The foot rapidly loses its spasm or pain, the
arch rises and the defoimity is temporarily
relieved When these occur, exercises should
be carried out Those most to be iccommended
are tip -toe movements Their object is to
strengthen the flcxois of the toes, especially the
long and short flexors of the gieat toe These
movements should be catried out n^ rhythm to
the swing of a pendulum or to the beat of a
metionome After a few minutes' exercise twice
a day complete lest is advisable Passive
exercises may be earned out as follows — The
nurse takes the foot and performs a combination
292
DEFORMITIES
of extension movements at tho ankle with rota-
tion at the medio-taisal joint inwards
tiupporti — In blight cases it is sufficient for
the patient to wear a Thomas' boot This con-
sists of a wedging up of tho inner edge of the
sole and heel, so that it is one-fourth to one-thud
thicker at the inuei than the outer edge In
very flaccid feet a valgus pad may be added
Numerous bandages are made, and many pads
and surgical soles, but the vulcanised rubhci
valgus pad is the best Whitman's brace is
often of value For this the foot should be
corrected under an anaesthetic as much as
possible, and a plaster cast taken of it, and the
brace modelled 011 the plaster cast Later 011
further correction should be done, and anothei
cast taken and the biace again modelled In
nivetciate cases it is necessary to cuiry up the
leg an outside steel suppott and to use a valgus
pad in the boot, together with a T-sttap to
invert the foot The treatment of the thud
degree of rigid or spasmodic ilat-foot - Before
anything is done the patient should be placed
entirely at rest for tlnee to foui weeks, and the
following measures may then be! employed
Foicible lectitication under an anesthetic and
retention of the foot in plaster, 0r the moio
gradual method by tenotomy, passive cxeiuses,
and the employment of a modified Soar-pa's shoe
Forcible lectincation is earned out eithei by the
hand or by Thomas' \\iench undei an an, esthetic
The gradual method consists in the first place
of lest, then division of the peronei and cxtensoi
commums digitoium, and occasionally of the
tendo Achillis, of the application of a malleable
iron splint, to be followed Liter by the use of a
Scarpa's shoo In all these cases it is essential
to keep up massage of the muscles of the leg
and the application of the constant curiont, and
so soon as the foot can safelv bear it tip-toe
exercises may be earned out Tho ticatment of
tho fourth degree — It is in this degice, and
when trenching under an anesthetic has failed,
that operative mtoiferencc on the bonos is justi-
fiable The measures which have been carried
out are lesection of the sub-astragaloid joint,
-extirpation of the astragalus and of the scaphoid,
transplantation of tho posterior part of the os
calcis, and excision of a wedge ftom the head
and neck of tho astragalus Of those six the
first and last are in vogue The first is known
as Ogston's operation — resection of the astragalo-
scaphoid joint It is done undci full antiseptic
precautions, and with a chisel the cartilage and
a thin layer of bone are removed from the
astragalus and the scaphoid m such a way as to
leave on the latter A concave surface The
bones are then pegged together with ivory, the
•wound closed, and tho foot put up m a plaster
case Stokes' operation consists in the removal
of a wedge of bone from tho head and neck of
the astragalus, fully adductmg the foot, closing
the wound, and putting it up in plaster After
all these opeiations great care must bo taken to
suitably support the foot so that no falling of
the aich oceuis Tho \\iiter has seen some
lecmrence aftoi opeiation Foi want of this
piccaution
MKTAIARSALOIA
Definition — This condition is a neuralgia,
often extiemoly acute, chiefly situated in the
an tenor pait of the foot All authois agree
that the immediate cause is piossuie on the
digital nerves at the head of the metatarsa!
bones According to Morton, the pain is localised
at the iniioi spaoo bet \\oen tho fomth and fifth
motataisal bones I Jut >oiyol ten one finds that
it has spi oad to the other digital spaces, although
tho pam is most sevoie in the ncighbouihood of
tho fouith mctattiiH.il bone
Vaitiatton — Thoio aie cases which show that
either ihoumatism 01 gout plays some share in
tho pioduction of tho disease, and in this way
those diseases cause a falling of tho antonor
t rans veisc arch oi the foot, and it is due to this
falling that the iioives become piossod upon.
The immediate incidence of tho disease is often
duo to a blow or a strain in \vhich tho weight
oomos more immediately on the (unit pait of
the foot In othei cases the pain comes on attei
long standing or walking, especially in nairow
boots In most instances some degiee of ilat-
foot is ptosont, and this is an nnpoitant point,
as the flatness of the postcnoi pait of the foot
has spread to the an tenor pait, and the meta
tarsal heads have fallen out of position in siu h
a way that pressure is caused upon the digital
nerves Mi Robert Jones has sho\\n that the
pam in the neighbourhood of the fouith incta-
tar&al bone is duo to falling of its head, and
piessuio upon the communicating blanch be-
tween the intciiidl and external plantar noi \ es
which passes beneath tho head of the fourth
metataisal bone In othci tases it seems that
it is not this communicating branch which is
picssod ii])on, but the intei -digital nerves
Xt/mjitoms — Tho patient complains of uther
a dull aching pain 01 intense boiing binning
pain, beginning m the front part of the foot and
ladiating thence up to tho leg and the thigh
The pain is such as to rcndci movement im-
possible It begins shortly after using in the
moinmg, and becomes worse before evening,
unless the patient take his boot off and rest
In fact, a voiy fiequent expiosHion is that " they
can got no lest until they remove then boot,"
and tins they must do no mattei where or under
\vhat cncmnstancch they arc Thoic is not, as
a rule, redness, although in exceptional cases it
is described as being piosont If one feels care-
fully, and takes a little trouble to pi ess the
metataiso-phalangeal articulations separately,
one finds that pressuie, especially ovei the
fouith metatarsal bone, readily elicits the pain.
It can also be produced by squeezing the foot
DEFORMITIES
293
with the hand acioss the heads of the metatarsal
bones. Fiequently the affected foot is broader
in that icg ion than is nonnal, and on examining
the sole one or two corns will be found, usually
over the heads of the thud and fouith metatarsal
tones These corns are indicative of the fact
that those metataisal heads have fallen out ot
their nonnal position Fiequently, too, there
is a peculiar twist m the foot, the portion in
front of the tarso-inetaUrs.il aiticulation is
twisted inwards, so that the base ot the fifth
metatarsal bone is exposed to the piossuie of
the boot, and the patient complains ot constant
pain at that spot
Diaqnw* — Foimeity this affection was con-
founded with gout 01 rheumatism, and vain
efforts were made to tieat it It is sometimes
mistaken foi fiat-toot, and, as we luue aheady
mentioned, flat-foot is piesont in many of these
cases But it is not the flatness of the postenoi
pazt of the foot which gixes rise to the acute
pain It is acute uemitis ot the digital neivcs
As to /^or/now, in seM'ie cases the only
impiovemcnt 01 cine that can be effected is by
operation
Ttintment -In .ill instances it is advisable to
hcaich ioi evidc-ncr of iheumatism or iheumatoid
arthntis and gout In slight cases the acute
attacks of pain may be lelieved by u»ino\iiu>
the boot and soaking the foot in hot watei ,
and the application ot the oleates of moiphia
and ati opine may tcmpoiaiily iclie\e the pain
If toots designed on the following plan aie tiled,
they will be found useful They should be
nairow in the instep, so as to lompiess the
bases of the metataisal bones, and wheie UK*
heads ot the met.it.usal bones aie, theie should
be depiessions hollowed out in the sole so that
pressure is boine in walking not on the heads
ot the bones but behind thnn Veiv otten,
howe\ei, one finds that this measme tails to
gi\e lehef , theie aie then the following anuses
open — either to exscct the nei>c, or to amputate
the toe, 01 to lemrne the head of the metataisal
tone aiound which the pain is greatest As a
rule this is the fourth, and it is astonishing to
obseive the good effects ot this proceduie The
pain immediately disappeais, never to return,
and the mechanism of the toot is in no wise1
inteifeied w ith In fact, it is the one proceeding
which gives pcimanent lehef
How-L,K«H (Cum ED Tmi\ AND FIBULA)
CCLUM* — Congenital (urvatuie of the legs is
due to malposition in titeio It is usually asso-
ciated with shoi temiig ot the limb and talipes
oqumo-varus The curve is usually anterior,
and at the convexity of the cm\e there is
frequently found a depiession in the skin
This has l>cen thought to indicate that com-
pound fractuie has occurred m vteto Hut this
is not so. Treatment is generally of little \alno
m these canes, but after childhood
when the
talipes has been corrected a wedge-shaped piece of
bone may be remo\ ed from the tibia. Osteitis de-
tormans and osteo-malacia give rise to curvature
in the tibia and fibula as in the othei long bones
Ttaumatic cm witine of the bones arises most
frequently from fractuie
It is also met with aftei injuiy to epiphyses,
either of the tibia oi fibicla The growing powci
oi one cpiph^sis is arrested, while that of the
othei remains unchecked, so that the longei
bone is invariably bent Such cases, however,
aie lathei of the natuie of surgical curiosities
tfyjthihtie cinvatute is interesting, and is more
j frequently a manifestation ot the congenital
j foim of disease than of the acquired It
should be caietully distinguished from uikety
tuimttne by the following points In the
s}philiti( foim the curv is purely anterior,
while in the iickety foim it is anteio-external or
anteiointernal The syphilitic cui\c is usually
situated at the middle ot the shaft, while the
nckety cuixe is incite often in the lower thud
The ciest of the tibia in a syphilitic cuive is
smooth and i minded, and in a rickety curve
sharp, while the surfaces of the tibia in the
former are com ex, and in the latter flat or
concave S>philitic cunatuie of the tibia is
best appieciated by looking at the tones from
the side, when it is \eiy stiikmg 0*teo malacia
mid osteitt* detoiman* also cause cursature of
the bones of the leg , the most common cause,
howevei, is nckets
Appeal nates — In inkcty bow-legs the tibia
is flattened from side to side, and the curve is
generally most maikcd at the lower thud The
medullaiy canal is often nai rowed in the middle
ot the shaft ami onlaigcd at the extremities
On the concave side of the cune the Ixme is
much thickened by tiiib-pcriuste.il deposit, which
acts .is a suppoitmg Initttess to the arch
Cunatme may take place in almost any direc-
tion, but the following types are found — (a) An
fjitetntti cmmtute geneiallj situated «\t the
junction ot the middle and lower third of the
leg (ft) A moie or less anteriot cmvatwe of
the tibia occupying the whole length of the
bone 01 onl\ the upper or lower third In these
eases the heel is otten laiscd, the loot pointed,
and in w .ilking is in a position ot equmo-valgus
(() An tntental cinvatitre is piesent with flat-
tening of the bones and the feet in a vaioid
position Of these three types the first is
common and the third lare Occasionally there
is seen a case with an internal euivc in one leg
and an exteinal curve in the othei
Pioynws — In bow -legs theie is always a
tendency to spontaneous rectification This m
slight cases is often complete, but in severe
cases only partial It is therefore unwise to
allow any case to pass untreated, since, if the
bones are soft, slight cases may very quickly
become severe
Tteatment — The method depends upon
DEFORMITIES
whether the bones are soft or eburnated, and
upon the direction of the curve and the age
and social status of the patient. If the bones
are soft no operative measure is called for, and
all forms of curvature except the marked anterior
are amenable to mechanical treatment when the
bones are soft. (1) Constitutional treatment of
rickets with local manipulation. — This method is
suitable for babies who have not yet walked,
for children who are not weighty, and for those
in whom the bones are not unduly soft and the
curve is a general rather than a localised one.
The manipulations are easily carried out by
means of the nurse, and should be so done as to
rectify the curvature. (2) Constitutional treat-
ment witfi mechanical support and manifmlation
is adapted to the following cases: — When a
curve^ originally slight is becoming marked;
when a child is weighty and cannot be kept off
its legs ; when the curve is localised in one part
of the bone more than another ; and when the
child is under four years of age and the bones
are not hardened. It is not necessary to keep
the child off its legs provided that the splints or
mechanical apparatus are acting efficiently so as
to control and diminish the size of the curve.
The simplest form of apparatus is an inside
wooden splint from the internal condyle to the
internal malleolus for external curvature, and
the reverse for an internal curvature. But
when the curve is compound, i.e. when it is
antero-lateral, a trough splint may be used with
the angle of the trough placed posteriorly and
internally so as to act as an opposing force to
the antero-lateral curve. Should the curve bte
mainly anterior, a more elaborate apparatus
must be ordered.
OPERATIVE MEASURES.— These are osteoclasis
either manually or instrumentally, linear osteo-
tomy, and removal of a wedge from the bone.
Operative interference is called for when the
bones are so hard that mechanical treatment is
out of the question ; in children over four years
of age; in cases of severe anterior curvature,
and in marked instances of lateral curvature.
With regard to the choice of operation, the
majority of surgeons prefer osteotomy, but some
elect to perform osteoclasis. In young children
in whom the bones are not very firm manual
osteoclasis is to be preferred. It is carried out
by fixing the thumbs at the summit of the
curve and using them as a counter-resistance to
the hands placed at the extremity of the curve ;
by a sudden combined movement of the two
hands against the thumbs the bone is quickly
snapped. Care must be taken that the bone is
completely broken and not merely a greenstick
fracture produced. Instrumental osteoclasis is
carried out by one of the numerous osteoclasts.
The advantage of osteoclasis is that no open
wound is produced, and the fracture is simple.
The leg is afterwards put up in splints or
plaster of Paris. Osteotomy is of two kinds,
either the linear or the wedge-shaped. The
limb may be put up into plaster of Paris. The
removal of a wedge is rather more difficult, and
much less satisfactory for the reason that it is
often difficult to completely divide the perios-
teum posteriorly, but wedge-shaped osteotomy
is called for when marked anterior curvature is
present. The wedge is best removed by the
chisel. Sometimes non-union occurs after these
operations, and it happens more frequently than
is suspected; but considering the enormous
number of osteotomies that have been performed,
it is not a very serious danger.
GENU VALGUM, VABUM, AND HECURVATUM
Definition. — Geuu valguni is a deformity of
the lower extremity in which, if the legs are
fully extended on the thighs, an angle obtuse
externally exists at the knoc-joint.
Varieties.— Rickety ; static; rachitis acloles-
centiuin ; traumatic, such as follows fracture of
the lower end of the femur or separation of the
epiphysis; inflammatory, duo to ostitis about
the lower end of the femur; and lastly,
paralytic.
Causation. — Three causes are assigned — bend-
ing of the lower part of the shaft of the femur and
upper part of the tibia, unequal growth of the
epiphysial line, and relaxation of the joints.
There can be no doubt that in rickety cases
relaxation of the internal lateral ligament is the
primary lesion, the internal condyle becomes
prominent, and the other structures become
adapted to the altered position of the limbs.
The results are as follows: — Shambling gait,
contraction of the biceps tendon and of the ilio-
tibial band and external lateral ligament,
rotation outward of the tibia, lateral mobility
of the knee-joint, and some obliquity of the
pelvis, and occasionally scoliosis. Flat-foot is
very frequently seen in association with genu
valgum.
Mymptotns. — When the affection is coming on
the patient complains of some difficulty iu rapid
progression, pain and tenderness over the in-
ternal lateral ligament, and becomes very readily
tired.
Treatment. — In the rickety form the most
important thing is to treat the constitutional
trouble. Now in static genu valgum there are
two stages met with, relaxation of ligaments
and muscles, and osseous deformities arising as
the result of relaxation. These stages afford us
a guide in treatment. For neither in the
softened stage of the bones in rickety genu
valguni, nor in the early stage of relaxed muscles
and ligaments in the static variety, should an
osteotomy, nor an osteoclasis, be performed.
The means at our command, therefore, are
general treatment, rest and local manipulation,
mechanical treatment, and operative treatment.
The general treatment is that for rickets.
Manipulations are best carried out as followB :
295
— The tibia should be biought firmly mwaids
with the right hand, while the left hand is held
firmly against the lower part of the femur
The knee -joint must be maintained at full
extension while these movements die earned
out Thieo or four movements inward aie
made, and the limb IH allowed giadually to
come back to its onginal position It IH im-
portant that the child should wear splints The
simplest uphills an* the long wooden outside
splints, with a knee-cap fitted to them, <uid the
Hplints secured loimd the pehis The more
costly and nunc efficient airangcmcnt consist*-
t»f an outside steel suppoit fiom th«j lx>ot on
both sides, and fixed aiound the waist by a
steel pelvic baud Most eases ieco\ci in about
nine months to a yeai undei the combined
effect of rest, change oi .in, good feeding,
manipulation and splmtin^s But fin thos<
that do not, opeiative mensuies aie called foi
These aie osteotomy, osteoclasis, forcible manual
rcctifitfttion of the knee Osteoclasis has been
adopted of Lite, and appeals to be likely to
displace osteotom\ The object of osteot lasis is
to iiactuie tin iemiii just above the knee-joint,
a somewhat difheult pioceeding to cany out
exactly Foi this end A.UIOUS tonns oi osteo-
< lasts 01 wicnches aie used Personally, the
vvnter is not in faumi ot osteoclasis foi genii
valgum, he much pieieis osteotomy, which is
done cithei by Maccwcn'soi M,ie<nm.ic's method
Foi piactic il pm poses the lattei method is
best, and the wiitei is accustomed to use a saw
in place ot a chisel Ogston's opeiation, 01
sawing off ot the mteinal condyle, is by 110
me.uis so good «in opeiation as Maeewen's 01
Macoi in.it 's, and in some cases <listmct stiffness
ot tl»e knee has followed sawing oft ot the
mteinal condyle Altei the opeiatiou the limb
should be put into plastci of Pans ioi six weeks
to two months, and subsequently it may be
necossaiy to move the knee undei an an.esthetic
(reau ratum — Dilution — CJeim vaium is
that condition oi the legs in which a line diawn
fioni the iie.id of the iemiu to the middle of the
ankle-joint ialls inside the centre oi the knee
joint
dauvition — In the majonty of cases iK'kets
is the chief cause, and gcnu vaium is in such
instances constantly found associated with
curved tibiic Indeed, the so-called genii varum
is not limited to the knees Theie is a geneial
outwaid convexity of the femur and tibia, and
.is the knee happens to 1x» situated veiy nearly
in the mid-length of the limb, it is the most
prominent pait of the convexity. («enu \arum
is also met with aftei operation for genu valgum
as the result of ovci -collection It also anses
from occupation, and is met with subsequently
to excision ot the knee (Jeuu \.trum is seen
of all degiees from slight to veiy considerable
deformity The nature of the affection is
evident at once on looking at the patient, and
the treatment is conducted on the same linos as
genu valgum In cases in which the bones are
soft, and the ligaments relaxed inside, splints
with manipulation and massage are sufficient
When the bones arc eburnated, osteotomy at
the gicatest point ot cimuaure m the limb is
neccssaiy
on — A defoimny chaiactensed by
hypei extension ot the knee-joint
OfduieMe — It is soui associated with othei
(OiuliMons, namely, congenital and paralytic
club foot, iitkets, defoinuties ot one limb where
.in excessive ••ti uu has been put upon the sound
limb , also in Charcot's disease, and as a pnmaiy
( mid itum in con genital displacement of the knee
It the detoinnty is a hindiamc to piogiession, a
walking appaiatus with a flexion spring at the
joint should be woin, or aithiodesis must be
pi i foi mcd
Cox A \ AR\
(iNrUlUAUON 01' nil NK< K. 01 'MIL I RMUR)
Dt pint inn — Coxa \ara is a pecuhai bending
of some poll ion oi the upper pait oi the. femui
in such a way th.it the head of the bone sinks
dow nw aids This bending takes place m one oi
two positions, eithei at the neck, so that the
head becomes hou/ontal and is often twisted
foi w aids, 01 the bend takes place lust below the
tiochantei ininoi, so that the .shaft forms heic
an obtuse angle
Cnuvitwn and 7JnfJtol(M/y — The most usual
cause is undoubtedly i ickets, but there aie othei
less well-known factois at woik Softening of
the bone oiten occuis m adolescence, and lias
been asenbcd to rachitis adolescentium, perhaps
without sufficient leason In l»ys who cany
heavy weights, the neck of the iemui sometimes
gnes It is quite possible that some of the
cases ot coxa \aia aie due to slight mflammatoiy
change's with softening at the epiphysial line
The affection is moie common in males than
icmales, and is moic often unilateral than
bilateial
Th«* net k ot the femui giadually yields until
the. head ot the bone is on a le\el with 01 below
the top of the gieat tiochantei The neck is
also bent in such a way <ts to foim a cuive with
the comexity backwaids It is m this class of
case that the difficulty m complete tfexion oi the
thigh is met with In a second \anety of case,
namely, bending outwaids of the shaft just
below the trochanter, this flexion difficulty is
not encountered
Kyinplotnt — In adolescence, without apparent
cause, 01 following slight injuiy, the patient
begins to limp and to complain qf fatigue and
pain about the affected joint on exertion
Shoitcnmg of the limb is soon apparent, and is
accompanied by elevation of the trochanter
abo\e Nelaton'i line The limb is sometimes
296
DEFORMITIES
flexed to a few devices, and is often routed
outwardb Abduction of the limb is also lessened
In fact, symptonib m.iy be bummed up as follows
— Poculmi stiffness of the hip, letciicd to
"growing" pains , the stifhiess is woise on
using after Hitting foi a time, but is relieved b)
complete icst , limping, if one side is affected ,
waddling, if Ixrth , shoitemng, amounting to .is
muth.is 1J inch . piommence oi the tiothanteis,
especially on iieMiig the thighs , displacement of
the tioclmntci atxne Nelaton's line, and back-
wards as well , lotatiou outwaids of the limb,
and eu'isinn of the toot, limitation of imeision
and final loss oi .ilxliu tion, \\ith, in .in cxtiemc
case, " bcissoi -legged '' pi omessioii and inabiht}
to walk without ciuUhos, tiltmu of the pelvis
and consecutive scollops The signs which aie
absent aie — Suppmation, thickening of the
trochantei, tendeincss on piessuie, absence ot
the up-and-down moAeuieiit on ti action ehaiac-
teristu. of congenital hip displacement
Difn/nwtv — It IK \ei\ difficult to distinguish
eail) coxa A ai, i from (oxitis, and tlu1 admmistia-
tion of an anaesthetic is often called foi, but
thcie can be no doubt that a small numbei ol
cabcs diagnosed as incipient <o\itii]>rmo to be
coxa >ara Fiattuic of the ne(k ot the femui,
uppei pait ot the shaft 01 sepaiation ot the
epiphvsis, especially it not seen until some time
atter the aendcnt, nitn be difficult ot identifica-
tion So too may coiii-cnital dislocation ot a
slight degiee, but in the liontgcii lajs we ha\e
a most \aluahlc means at oui com maud foi
diagnosis
Ptoynov* — Complete ie,st quit kl} lolicuw the
pain, and the depicbsion of the head and neck
of thefemui cease, and in »ome eases the length
of the limb may be icstoied In ti action If
the dcfoimiU is left to itselt, the patient can
scarcely hobble along on account of the exceed-
ing adduction of the limits
Treatment — hi the eaily stages entne lest,
local massage, and passne motion in the
direction of the limited movements mil effect
much Failing these, complete lecumbcm)
and the employment of tiaction to the limb
aie of service When the depiession of the
head has apparently i cached its limit, an
oblique osteotomy thiough the gieat tioehantei,
with the limb subsequently put up at an angle
of alxhiction of about 25 01 30 degices, will
do much to icmedy the deformity. In those
cases in \\hieh the bending is in the shaft just
below the trochantcr inmoi, the \vedge-shaped
osteotomy is of scivicc The subsequent use
of the cork sole will be necessary on account
of the shoitening if the affection is imilatcial
KTIOLOGI ov(D((/eneiact/), INSANITY, ns NATUKK
AND S\ Mil QMS (In vine J)t(it/n"un, Deycunact/)
Degenerates.- Those suffenng fiom
dcueneiaey, those AN ho have lost, cithei in
mental powei oi in physical development, some
of then lacial chaiaeteis *S'«' Hii'NfnisM
C/'/ieHijtetitH' c7s<"» tn Vnnm*> tnul Def/enwnfr
Clnlthen)j LiiNA<\ (Definition, "degenciates") ,
PAKA>OIA (Sy^ttMiitivil Infinity in thr De-
Degeneration.— A pnuess oi dec a) or
dismtegiation 01 ti«in,sfoimation by ninth the
life of the tell* oi an oigan 01 tissue is interfeied
\\ith so that the functions of the pait aie less
, peitectl} peitoimed oi me not peifoimcd at
• all , stnctty speaking, the cells continue to li\e,
although in a cnpplcd condition, and aie able
, to peifoim then tunctious 111 .1 de^tectixe fashion
i 01, peih.ips, to pel f oiiii fumtions ot a lower
I oidei , degeneiations aie with dim* ult\ separati'd
j fioin mtiltiations Some ot the best known
1 dtgeneiations may be named amjloid (wa\\
1 01 lardateous) degcin lation, atheiomatous,
! caltaieous, caseous, colloid, (vstic, fnttj, fibicud,
1 tibiotatt^, uiannl.u, h\ aline,' mucoid, paienehv
matous ("cloudy swelling' ), and pmuieiit.iix
degeueiation
Degeneration, Nissl's.— Thee haimeH
winch occui in a neiAe cell when the axon is ( ut,
such as dec lease in the ehiomatmof the nucleus
with displacement ot the lattei to one side, etc
A>Vf PinsitjifNii, TISSLLS (Nenv, Itttet tdatntti-
*hi]t fit JTanftm)
Degeneration, Reaction of.—
"\\hen, in the gahanic stimulation of a muscle,
sepaiated tioin its nei\e, the .niul.il closmu;
(ontiaction becomes much exaggeiated, it is
said to SJIVP the tent turn ot tlt</eHt>atntn >SVv
, TISSUES (Miiv
Deglutition. — SwallovMiig Nr AKO-
umisM (Motin I'tnttttKni^ fnijKininetit of Df-
' '//iifitif/n) , BRAIN, AM hciio\,s or BroooA J>SEIS
(PaialyMjttnn Vn\mhn Lfwtv^ J 'tenth >-/m that
I'ntafytts, Rrftn"*) , Kii \i\, (ii. KEJJKI I.L M, A M>n -
U(»H oi (7'wmrwo, Diffitultif fit Dey/ufi taut ),
(!AM, RENE or (f)w//Htiti<>n
) Musn KS, DISK \SEH ob ( 7'* uhnnnv *,
Iiujtltctittiw »f J'hatt/mtui/ Jfuvtet) ,
, Foon AND DioiksnoN
Degeneracy.— The fail me to leach the
normal of healthy dc^clopmcnt as seen in the
loss of that degiee of mental powei and
physical completeness which is the natuial
heritage of the indnidual Nee INSANITY, | seen in the insane.
DehiSCence.— Splitting open 01 burst-
ing, erf the dehiseeiue oi a (iranfian follicle in
the o\aiy duimg OMI lation ,sW (>R\hitATiONf
FMIAIE OHGAIN.S OF (0>'<nt<i)
, Dehumanisatlon. — The loss of
human chaiactcribtics (mental and physical) an
DEITKRS' NUCLEUS
297
Dorters* Nucleus.— Themiddlenucleus
(111 the pons) of the outer \cstibular nucleus of
the vestibulai root of the eighth ciamal nerve
*SVc BRAIN, I'jiiHioiom or (diantat AMMS),
PmsiOLOov, NHtxoLsSt MEM (MiduttaOWtmtjttfti,
Cetebel/um)
Dejection. — The act of emptying the
bowels, 01 the matteis evacuated horn them ,
also, mental depiession Mejectio ammi)
Delayed Labour. ><><• LAHOLH, I'BK-
Cll'llAfK AND I'KOIOMihll, etc
Del h i^Boi I. »S'« FURUNT UT us ORIFN r \us
Del Iff at Ion.— The hgation or tying of
HI tones
Deliquium Animi.— Mental failing,
fainting , deiectio annni
Dellramentum. — Dciuium (dot nod
piohahly fiiini tie, f 10111, ami lntit a tuiiow, and
meaning, theietoie, a deviation fioni thcnoimal
standaid of mental health), the French \\oid
dflne, it is to he noted, means in.tnia .is well as
deliruun, thus dttnc <m/u is acute mania
DellriantS. — Gcneial cerehial stiinulants,
causing mental excitement, such as belladonna,
stramonium, hyoscyamus, alcohol, tea, cofiee,
coccu, tobacco, cannahis indica, opium, et(
Some of these clings have hist a stimulant and
later a depiessinn or paial^smg influence, cy
opium
Delirious Mania.- st M»M M* —A< ate
dfdnoH* nmiiui tfe/nntm <n ntum, Jitll\ mnnin ,
typhrntHium
Definition — An acute deliiium chaiac tensed
by piecipitate onset, rapid couise, k«M»if extieme
piostiation, and usual 1} f <it.il issue
J/ittoiy — This disease was desciibed hft\
yeais ago by I)i Luthei Jk'll as "a loim oi
disease resembling some adxanccd stages of
mama and ie\ei " Since then numeious cases
IUIAC been icpoited in Ameiica, in this count ly,
and on the continent The teim acute delirious
mama has unfoitunately been iiequenth mis-
applied to se\oie cases of mania 01 of evened
melancholia, and in consequence some ohscncis
have been led to doubt the existence of Hell's
mama as a distinct clinical entity This \\ould
appeal, ho\vcvei, to be a mistaken vie\\, as there
is abundant oMclc-nce oi the existence of a quite
sharply chaiactensed acute dehnous mania such
as> Bell described
Etiology — Most of the eases occur bet>\ een
the ages of thirty and fifty The patients are
frequently of neurotic constitution, and the
symptoms may follow \vorrj, over- \\ork, oi
disappointment Othei cases have ansen in
association with pneumonia, septic infection,
insolation, alcoholism, and injury, especially of
the head
Xymptom* — Theie is nsuall}, if not always,
a prodromal stage dining which the patient
snffeis from lassitude and dcpiession of spirits,
and often also fiom insomnia The acute stage
of the disease is enteied on suddenly, and in
the couise of a fe\v minutes the patient mav
pass into a state oi the wildest excitement \vith
vivid hallucinations, delusions oi no h\cd t\pe,
and outbreaks of gieat Molencc He lushes
about gehtic ulatni". talking, singing, laughing,
iijm« He ictuses tood, ami is entirely sleep-
less This dc'linous stage m.iy contiinio foi
se\eial d.iAH, until at length he passes into a
condition of extieme piostiation The nune-
ments becoiiu- ,ita\u , «md ale interiupted b\
twitching ind spasms The talking is replaced
b} an unintelligible miitteiing The tongue is
iiou fonnd to be (o\( led >\ith thick fin Sordes
appeal upon the teeth The pulse is quick and
ieeble The tempeiatuic is ioiuul to be iiom
foui to si\ degiees abcne the noimal The
\i hole aspe< t of the patient is that oi piotound
nei \ous e\h<uistion The appeal ance of this
typhoid &t.ii:e ih \ei\ (haiactenstu, and sug-
gested the name tjphomama ongin<ill} aj>plied
to the disease by Uell,
The eailj excitement, the \iant of food, and
the want of sleep icsult in lapid wasting oi the
bodv, which may become quite extieme undei
ihediam of a colhquatno diaiihua which some-
times sets in Puspnation is often piofuse,
and eruptions, pustulai, bullous, 01 peteclual,
mav be piesent The urine ife sc.mt\, high-
(olouied, <md m.i> be albuminous (iiaduallv
tin* patient sinks into deep coma, and death
takes plate in horn thue days to thiee weeks
horn the onset oi the deluium In the laie
eases that ieco\ei, the p.itient does not become
comatose, but j)«isses thiough a piolonged con-
\ales<eme, legainmg his bodily and mental
health \ciy slowl\, .md oiten impeitectl}
y*>o//Hf>s/s — As ahead} stated, the disease is
usually fatal, but the mentality is \aiiousl}
stated b\ difteicnt w liters When death does
not occui a good deal ot mental feebleness,
amounting exen to complete dementia, may be
leit behind
I'atholof/y — The pimcipal anatomic al changes
aic congestion oi the memnges and of the cere-
hial coitex, and occasional!} aieas oi softening
Tunc'tate hemorrhages aie piesent, and leuco-
c}tes an<l red bl(M>d-coipuscles aic found in tho
pemasculai sp<iu>s
The disease appeals to be .in acute infection
Oigamsms ha\e been isolated from fatal cases
Rasoii, foi example, obtained fiom .in area of
softening in a fat.il case pine cultures of a small
bacillus with lounded ends which grew in the
oichnai) cultuie media at the temperature of
the bod\, 01 ot the loom, and which was stained
b} the oidmary aniline dyes, but not by Gram's
method Rabbits inoculated beneath the dm a
died in two days , beneath the skin, in four to
298
DELIRIOUS MANIA
six days , and in both cases cerebral congestion
and oxlema were found
Diagnovs — The clinical histoiy of Bell's
mania differs considerably from th.it of oidmaiy
acute mania 01 excited melancholia, though borne
difficulty may be cxpcnenced in diagnosis during
the pcuod of excitement The piccipitate on-
set, the extraoidmary intensity of the symptoms,
the i.ipid changes in the ti/jie of the delusions
and hallucinations, and the fcvci aie points ot
impoitancc Uieatci dithculty in diagnosis is
sometimes picsented by othei febule diseases
associated \\ith delnium The deluious stage
of Bell's mama IK sometimes of very buet
duration, and tin* patient quickly passes into
the condition oi piostiatum, to which the term
" typhoid " h.is been applied In this condition
the case is leadily mistaken foi one of typhoid
fevei, but a (onsideiation of the histoiv, ex-
amination ot the patient, and the use of Widal's
tost should lead to a conect diagnosis Acute
pneumonia \\ith delirium, and uitemia with
maniacal symptoms, may give rise to dittii ulty
in diagnosis The disease can baldly be mis-
taken for delinimi tremciiH A febiile deliimm
occasionally occurs in association vith ma I anal
poisoning
Tteatnttnt —The tieatmeut of this disease
cannot leadily be aimed out in a pin ate
house, as the patient dining the eailv stage
is excessively noisy and often violent Tin1
patient is best kept b\ himself in a laige, tool,
daikened loom, and mused by experienced
attendants He should be kept in bed, his
mo\ements being limited by the use of a
restiaimng sheet Foiccd feeding \\ith con-
centiated fluid nourishment at shoit mtei\als
is essential Some enters lecommend the
admimstiation ot a calomel purge at the outset
None of the hypnotic drugs seem to give xeiy
Hatisfactoiy results Opium is considered dan-
gerous Ilyoscmc is sometimes useful m limit-
ing the excessive musculai activity, but must
be used \\ith great caution Sevewl \vnteiH
stiongly lecommend the use of eigotin Alcohol
should not be used in the eaihei stages, but
may prove of gieat value mhen the pulse is
failing
In cases \\hcie iccoveiy is taking place,
careful musing toi a prolonged peiiod is
ncccssaiy, and the patient must be guarded
veiy caiefully fiom .ill excitement and fatigue,
such as is entailed by too early visits from
fi lends Aftei i ceo very the patient should,
if possible, go to live quietly in the countiy 01
at the sea-side, and i chain entnely from mental
woik for at least a year
Delirium. >SW also ALCOHOL (Acute
Alcoholic Intoxication), ALCOHOLIC INTHAVIT\
(Delirium Ttetnenv), ALCOHOLISM (Delnium
Trentem) , AORT\, THORACIC, ANEURYHM
(Symptom*), BIUIN, AFFECTIONS OP BLOOD-
VESSELS (Ancemttt, Hypftcnnui, (Edema},
BRAIN, INFLAMMATIONS (Acute Encephalitis),
CHOREA (Cfuotfic Inwntty, Acute Delnium),
DELIHAMENTUM , DELIRIOUS MANIA, DELIRIUM
TUEMENS, FRACTURES (Constitutional tiymptoms,
Delnnnn), HEART, MYOCARDIUM AND ENDO-
CARDIUM (ti?/iiijitonmto!o</yt Ceieuial tiyniptom<i) ,
HEART, MY oc \RDIUM AND ENDOCARDIUM (Pulse
in Mutfle Fai/ine, Delnnitit (loidn) , HYSTERIA
(Convulvonv, Penod of Del n nun), INSANITY,
PxTiior <H,Y oi« , INSANITY , NATURE AM> SY MPTOMS,
LAHOUR, PnitriPii ATE AMI PROLONG*.!) (Obitmcted
LnltttHi), MKASLBS (,S'y/w/tfows, Delnium) ,
MBXINdiriS, TULJfcRC'ULOUS AM) POSTERIOR BASIC
(tiymjitoiHv) , MORPHI VOMAN1A AM) AL1 I hi) DllUd
HAHIIS (Patahleht/de), PNEUMONIA, CLINICAL
(Xymptom^ Tmitntrnt) , PrhKPhitiUM, PAIHO-
L0(,^ (JttvinitH",, ('hatful VnnctHt), ShNlLE
INSANIT\ (Defnmm ot (lolfiij)*?) , TRADES,
DANGER™^ (Lfad-Poi^nnntj) , TYPHOID FEVER
(Kt/niptoiHv, tff tinai tii/\tem), TOPHUS FEVER
(l*fi tod of Ad w net, Si/ittptomi)
Delirium Grandiosum. — Mono-
mania of <iiandciu , (Jeneial l'aial}sis
Delirium Mussitans. — Mutteung
01 quiet delnium
Delirium Tremens. X'f a/s» DE-
i IKIUM and (hoss Kefeienees — Delnium tiemens
(HHIHKI a pot 11} is essentially an insanity ot shoit
duiatum, occ lining in the couisc of chiomc
alcoholism, and due not to the dncct action ot
alcohol on the ncivous system, but to nutiitive
chinges bi ought about by usuallv long-continued
alcoholic abuse It is chai.u tensed not only by
tx»mpoi«uy men till alienation, but by distuibances
at a lowei level mdi&itcd by niotoi and sensoiy
symptoms
SYMIMOMS —The onset of the attack is fic-
quently detei mined by a tempoiaiy excess, or
may be piecipitatcd by the occunence of an
accident oi the subvention of some acute
illness su< h as pneumonia The patient \\ ill
almost always be iound to be a ion firmed tipplei,
although it not inhcqucntly happens th.it lie
has seldom 01 nevei been actually drunk
At the outset of the attack the patient often
complains of sleeplessness at night He suffeis
from gieat distaste foi food, and often for a few
days foi dunk also His mo\oments are noticed
to be markedly ti emulous In couveisation ho
is apt to be somewhat incoherent, and his atten-
tion is difficult to h\ The acutei symptoms
frequently come on at night He becomes e\-
ticmoly lestless, and is the subject of a busy
delirium in which he zanders about the room
moMiig the chans 01 ai ranging the bedclothes,
talking constantly the while He is very sus-
! picious, and fiequently looks behind the curtains
I or under the bed to see it anything likely to
hurt him is concealed there. Visual hallucina-
tions appear, usually of a terrifying nature,
DELIRIUM TREMENS
299
whence the disease has acquired its populai
name of the "horrors" The ten or inspired
may bo HO great as to lead him to jump out of
the window or run into the street halt naked
Auditory hallucinations aie less constant, but
aie not rare
The tongue is moist, tremulous, and coveied
with a thick whitish-yellow fin The pulse is
rapid and soft The temperature is usually
model ately raised
After a few clays, in a mild case, the symptoms
gradually subside, and sleep and appetite loturn
The ticmoi peisists for a few days longer In
severe cases the couise of the disease is more
protracted, the insomnia persists, the distaste
for food is aggiavated and may be associated
\vith troublesome vomiting, exhaustion becomes
extreme, and death may occm fiom hcoit iailm v
In othei cases again the acute symptoms pass
off, but the patient lemains for a time the
subject of hallucinations, 01 of insanity \vith
melancholic delusions Aftei icpeatcd attacks
the In am becomes moic and nioie enfeebled
until a condition of dementia is reached
PIUM.VOSIS — In a stiong patient \\ith a healthy
t onstitution lecovoiy is the lule In all cases
the stiength of the patient, his histoiy as to
intempeiante anil pie\ioiis attacks, and the
seventy of the attack, have to be taken into
account An attack in \vhich the patient im-
agines he sees small objects such is spideis or
l>cctlc'S about the bed is apt, othei things being
equal, to IK' nioie gra\c than one in which he
sees lai »ei objects sue h .is eats and dogs Whcto
no histoiy oi long-continued mtempeiauce can
be obtained, the piesenco of penpheial neuritis,
mdic<ited by extreme tender ness of the cal \esoii
deep piessme, will tell its own tale All patients
must be examined caiefullyfoi e\ idence of acute
disease, particulaily pneumonia, the symptoms
of which .ne sometimes latent
TREAIMENT — Delirium tiemens being a self-
limited disease icsulting often in evtieme
exhaustion, the pimcipal indications foi tieat-
ment <ire to maintain the stiength and to piocuie
sleep The foimcr is best cained out by keep-
ing the patient in bed, and admmisteimg easily
assimilable nourishment — milk, strong soups,
otc — at shoit intervals K\ery etfoit should
be made to keep the patient in bed by pei-
suasion, but m cases with very gieat excitement
and violence it is bettei to lesoit to mechanical
res ti dint than to peimit piolongcd stnigglmg
between the patient and his attendants
As to protuiing sleep, it has to l>c lemembered
that in a mild case sleep will tend to come
naturally m the course of thioc or four nights,
and it is not advisable to push the use of hyp-
notics too early Nevertheless, m the majority
of cases the eaily excitement can be quickly le-
duced, the lestlossness and consequent musculai
exhaustion diminished, and the coming of sleep
hastened by the judicious use of hypnotic drugs,
although it cannot be claimed for them that
they cut short the disease As to the drugs to
be used, a combination of chloral and bromide
of soda judiciously administered and with due
regai d to the effect obtained will be found per-
fectly satisf.ictory in most cases Opium \tas at
one time far more used than at present Most
of the newer hypnotics have been extensively
tiled dining lecent yeais
Alcohol should be avoided as much as possible
i the tieatment of delirium trcmens Still it
is of value in a ie\\ severe cases with marked
piostiation, and especially m such cases when
complicated with pneumonia
After ieco\eiy fiom the immediate attack
further tieatment is indicated on the lines laid
down m the article "Alcoholism "
Delivery. «SVf LA HOUR, DIAGNOSIS AND
MECTI \NISM (TVriMvmiw Lte^ Njxnitantoui De-
fimty), LAHOLJI, M VNAI.EMBNT (Atta Deli vet //),
LtliOUK, PKEflPll VIE AND PROLONGED, LAHOUK,
FAUITH IN TIIE PASSENGER, LAHOUK, INJURIES
'10 THE (ihNEKVlIVE ORGANS, LAJiOUK, OPERA-
TIONS (Jnduition of Ptetrtfitiut Lalmm) > MEDI-
c I\E, FORENSIC (/Jtlivet y, *S'/</M«C oj) , PHW. NANCY,
AllECriONS ANIl ('OMPIICAIIONS, PllbGNAN'Cl,
Hl-MORUlIAGE (Ft)Ktd D(/H'<iy), PUERPERIUM,
PHYSIOI OCIY (Eoitlentti of Recent Delivery),
PUERPERIUM, PinsioifN.^ (Afannt/ruient)
Delphine. M
SIA\ isAc.ui fc SEMINA
Ai KAI OIDS (Detjtknuna) ,
Delta.— The fouith lettei of the (heck
alphabet (A) , the capital (A) is used as a sign
foi the1 f i ec/mg-point of the mine in ciyoscopy,
and the small lettei (6) foi that of the blood
/SVe Cm (>
»SVr MUSCLES, TRAU-
) t SHOULDER, Dis-
»/ys<« of the Diltoul)
Deltoid Muscle.
AFHS.CHONS
E \MCh \ND INJURIES o» (
De lunatlco inquirendo.— An m-
quisition in lunacy, authonty to inqiine into
the mental state of any one by a \\iit from the
High Com t of Chancei y »SW LUNAC\ (Lunacy
('ftaiu.eiy Lunatn^).
Delusional Insanity. ,sv,>
NATURE \ND SYMPTOMS (Type", of Episodic
/nvrin/y, Ddimowil »S'fi(/xif awl Infinity) ,
PAKANIH\ *SVr atw CHOREA (Chut tie Iiitniuty,
Dttuiiomil) , rriMAcnuur I\sv\n^ (Clinical
Foim^ Delusional)
Delusions. &< AT^OHOLIC INSANITY
(('linn a? Tyjxs), CLIMAC'IERICJ INSANITY (Insane
Delusion*), INSANIIY, NAIURE AND SYMPTOMS
(tiytteHiatic Deluwmt, Fued and Ptotpemve
Delusion,*) , NERNES, MULTIPLE PERIPHERAL
NEURITIS (tiymptonu, Psychical), PARANOIA
(Pioyrewwe Systematized Insanity)
300
DKMENTIA
Dementia. — Dementia was at one time
employed almost as if it weie a synonjm of
insanity , but now it has a more icstncted
meaning, signifying the moilml psychical t»t<vto
in which theie is enfeeblement (01 absence) of
intellect and will It is always .uquned, and
on this account the it1! in dementia wni/eiuta, as
a synonym for idiocy is an incoirect use ot the
woid Several vaneties are eimmeiated, among
winch maj be named dementia agitata, dementia
affottata, dementia alcoholic, dementia apathica,
dementia apoplectics, dementia choieic<i, de-
men ti«i chiomc, d(>mentia epileptic, dementia
paialvtica, dementi.i scmhs, dementia to\i<a
These names cxpl.uu themsehes Nee also
ADOLESCENT iNMAMn (I'u maty Dementia and
Dementia Attonita) , AICOHOLIC lNSA\m (Pet-
inaiient Dementia) , RHAIV, TLMOUUS OF (Dnujno-
***), CHORE \ (JftmlittnyAflvltChaten, Dun/no-
un), (I'KNKRAI. I* \RYI\MS (Nyn<wynm, Dementia
Patalytita) , INS\MH, PATHOLOGI OK (Change
in Cw tun/ &>) ve (Jell*) , [XHAMH, NAIURE AND
SYMPTOMS (Kiolouy Oj CttMIUfHtVHfi*) , iNHANm,
NATLHR \ND SIMFIOMM (Ptimaty Dementia),
MBMOU\ iv HKVIIII AMI DISKVSK (Pm/if<siw
Ammnai) , MENTAL DEFICIENCY (D> re/ojmientaf
CWi, tit/ji/tthti( ) , PAH \V)L\ (/'tm/tmtw >'//'-
temattwl InviHtty) , KKMLE iNhvxm (tiinyt/t
Dementm, (Jnuiplicntett Dement tn)
Demlssio Animi. — Pcpu-ssiou ot
spirits
Demme's Bacilli. *«> SKIN, HAC-
TGRlouxiV OP (/tactetta ulnittfinl vnth wni'tus
Dtieaw, Eiytliemn Xwlosum)
Demodex Foil leu lorum. ^
PAII \8irEs (Aiith>oj>ods, Amehnoitfett, Arnnnat
Demode r) , »Sr MHEs OH IITK Ticir (Otha AUDI,
Demwle
de r) , »S
let)
.— A void tecently intio-
duced, MiynifynijT the bf<> conditions of com-
munities in nations as sealed by {statistics of
births, mamayes, deaths, pre\alent diseases,
etc «SVr Yn IL Si VII«IIKN
rf)
. — Religious melan-
cholia in uhith theie arc delusions of possession
by evil spnitis , demoniac [jossession , demono-
path> tiee INSAMI\, NA'ILHK AND SYMIMOMS
(Mffauehftlia)
Demorphinisation. Xee MORPTHNO-
Demorphinisation. Xee MORPTHNO-
NTA (Treatment by withrhawi/ of the duty,
dden ot </tadiHt/, ot by substitution, of anothet
H<J)
Demulcents.— Sul)htanccs >\hich ha\e
a boothm^r, lenitive, ixnd piotective effect, suth
as aiacia, gelatin, gl \ccim, hone), starch,
tragac.inth, and \\ lute of e^
Den d rites. Nee PH\MOTOOYV TissiEb
(Nerve) — The biamlung processes which fonn
a netwoik in cloho proximity to a neive cell ,
they do not include the axon, but ausc from
the other pioccsses 01 deiuhous
DendrltiC Ulcer.—- Apeculuu branched
(01 tiee-like) ulcei seen on the coinca Nee
CORNEA (Jiid/oitt Afittwn*, Dendntu Ulcei)
Dengue.
DEFIMFION 300
(xEOCRAPUICAL DlM RIBUIION 300
EllOHH.V 300
CLINICAL FEAI'UHKS 301
DlVONOMS AND I'llOUNOMS 302
TutATVIENT 302
Nee at w EPIDKMIOIOGI (Neaviwil Flvctuattom)
S\NON\MS — Dandy, Bteakbone, Ihice day?
tew, Abu lolnti, Ktdim/a jwpv, Ncatlntina theu-
niatna, etc
DEI'IMIIOX — A specific disease, severe but
not danj»eious, usuall) distinguished by fevei
of sudden onset, intense muscular and joint
pains, and latei a mbeoloid eiuption Endemic
ui Mime countnes, it usuall v occuis m le^ional
epidemics, and hiiue oiijruialh iccoi;nised (1779)
has tin ice assumed pandemic piopoitions
(lEooRAPiiiCAL DibiitiuuiioN — Among East-
ein tountiu's, Arabia, ('hma, and p«uticulaily
India and the island countnes atljonung, an*
subject to its visitations
Epidemics in hunted p.uts havr mem ml on
all sides of Afuio, except the extieme south,
and m E^ypt and Xan/ibai espet iall)
In Kin ope its outbieaks luive been confined
to Spain, (hcece, and Asia Mmoi
In the Western Hemisphcie the list includes
Bermuda, the West Indies, Southern States,
paits of South AmeiKa, and even as far south
as Tahiti It has also t cached Sjdney and
Hnshcine in Austiaha
Spoiadic cases aie icpoited by Sandv\ith in
Ei^vpt, and .ilso occm m Aiabia, Zanzibar,
Beimudi, West and East Indies, and Honduias.
In some of these the disease \\.is apparently first
intioduced d\uin<; an epidemic peuod
ETTOIUOV — In suddenness, iapid diffusion,
.ind the enoimous proportion (sometimes as
i?re<it as foiu -fifths) attacked in a community,
dengue has no equal except influen/a Again,
in dependence on tempeiature and altitude it
icsembles yellow fever, which in some places it
has closely pieceded or followed, in the latter
event reproducing, according to Smait, the
features of the milder cases
Essentially a disease of the tropic*?, and u&uallv
selecting there the hot season, its ordinary limits
are given by Manson as 32 47 N and 23 23 S ;
yet in waim weather epidemics, ahvays checked
by winter, have extended to Southern Em ope
and Philadelphia
Coast and nvcr districts and low levels suiter
far moic severely than inland parts and high
DENGUE
301
altitudes, peihaps a icsult of floor communica-
tion, a possibility supported by the i.ut th.it
towns, paiticularly the duty, ovei nodded paits,
usually pi ovide the stai ting-point and clue? fiol<l
for its outbicaks Additional evidence that it
IH coinrnunicablc is found in the numberless in-
stances iccorded ot dncct conveyanc e of mfec tion,
the paitieulai liability of immediate attendants
on the wok, and in its advance along the tiade
lOUteS
All ages and both seves, too, seem equally
susceptible, .ind although (oloiued people have
occasionally suffeicd least, they evidently possess
no immunity
Although no oiganism has yet been definitely
pioved to be the cause, M'Laughlin found in
the blood of twenty patients, without exception,
<i miciococcus possessing unique biological diai-
actenstics, and succeeded in cultivating it in
media and in blood , he \vas, however, unable
to investigate furthei
Whatevci be the value of his losearthes, the
stiikmg leseniblauce in mode of spiead \\hich the
foiegoing facts show that it beais to othei dis-
cuses of pioved paiositic oiigin stiongly s\iggest
<i like cause — an oiganism dependent foi its
highest actnity upon high temperatuie, low
levels, lack of an -space, dnt, and oveiuowdmg
One cannot doubt its being communicable, but
its ocMinence in epidemic foim may depend
upon these othei f.utois, a supposition faumied
by the immunity enjoyed in 1871-72 by ships of
the Indian Squadion in fiee communication \vith
infected poits, and by the fact that, although
actually mtiodiued into some*, only isolated
cases oct lined Together with the shoit in-
cubation (a few houis to five davs), it would
largely e\pl.ini the chief aiguments against its
infectious natuie, namely, the laige propoition
almost simultaneously attacked, dependence on
local conditions, and presence of spoiadu (ases
before epidemics
CLINICAL FEATURES — The patient is often
attacked with absolute suddenness, and almost
at once piostiated, but sometimes piemomtions,
such as malaise, painful twinges, gastric un-
easiness, thu&t, headache, or lassitude, precede
the onset by some hours — moie frequently, in
Maclean's opinion, tow aids the end of an out-
break
Headache, seveie, peihaps paioxysmal, and
associated with a sense of fulness in the skull,
lapidly inci easing fever, and usually scveie
paint), usher in the attaek The hist intimation
is not infrequently given by t\\mges in a finger
or elscwheie, thence rapidly extending to other
parts of the body
Pain and sense of fulness in the eyes, v\ Inch
become injected and ferrety, aching in the loins,
and great susceptibility to external air, though
rarely definite chills or ngors, are also com-
plained of The skin is hot, with occasional
fugitive perspirations, and the face suffused
with a deep flush, disappeai ing momentaiily on
piessuie, and often attended by puffy swelling
This, which is not invariable, and is usually
transient, constitutes the initial eruption, and
may extend o\ei pa)t or most of the Ixxly.
With it the buccal mucous mcmbianc is fre-
quently involved, leddened, congested, or even
superficially uliciated, ^suiting in soicness of
mouth and throat Thioughout the entile ill-
ness anoic'xia is a pionnnent symptom, while
gastnc uneasiness, nausea, 01 vomiting are often
piescnt, especially after ingestion of unsuitable
food
The tongue is <oated or clean, with led edges
and enlaiged papilla?, the bowels aie usually
(onfined, and the mine is scanty and high-
colomed, though inielv albuminous
The pulse is" rapid 01 little affected, and the
lespnations aie humcd from pain and level
The tempc'iatme lapidly rises, peihaps as
high as 103 to 10">° K 01 moie, but declines
quukl} to find it maintuned above 102J being
in Kiv.ici's e\pciience exceptional Prt MOUH
disease, siuh as malaiia, may modify this, like
othei symptoms, by mci easing its seventy and
peisistence and making it moie ague-like
By giddiness, pain, and faintness the patient
is soon completely piostiated, and his sufferings
.ue nu leased by his exticme icstlessness No
postuie is comfoi table, while exeiy movement
causes mci eased toiment
Marked neivous symptoms aie laie, but con-
vulsions occasionally maik the onset 111 children,
and at the- extremes of life lesolution may be
attended b\ gie.it depiession Insomnia, too,
is a common teatuie , dc-lnium may a< company
high fevci, and tcmpoiaiy loss ot smell 01 taste
has at times been noted
The pains experienced may be mteimittcnt in
ehiiactei mid lefened to muselcs, bones, and
joints Theie is often an uneasy stiffness, un-
affected by passiv e mov c-ment, but acutely painful
on any musculai conti action, worse too after icst,
and f i eq uc-ntly coml nned w ith a sense of powerlcss-
ness Theic may be neuralgic, dull, .telling, or
bonnu pain, most noticeable in the morning,
sometimes metistatic, and possibly accompanied
by swelling ot joints
tfecond Ftaye — This hist stage terminates
aftei one to thico days, gr.ulually, 01 moie often
by crisis, maiked by piofuse sw eating and dmicsis
Bilious dianhd.'a <uid hannoii hages m,iy also occur
now or eaihei, paiticulaily epistaxis, which has
a great eflect on the headache With fall or
i emission of temperature the- pains abate and
the patient feels well, though debilitated and
perhaps subject to " lemmders," such as twinges,
anoiexia, languor, and irutabihty
Thud ,S'taf/e — From the fourth to the eighth
day of illness the terminal ei option appears,
sometimes attended by slight transient icturn
of fever, and the pains recur with, at times,
greater intensity than before This eruption is
302
DENGUE
extremely variable, and may be scarlatinal, rubeo-
loid, or urticanal , it IH usually present to sonic
extent. Tingling, itching, and numbness of
the hngens often foreshadow its appearance on
tho palma — its frequent starting-point It may
begin there as small rod spot-*, disappoaung on
pressure, which gradually coalesce and perhaps
spread all o\er the body, in some cases com-
bined with swelling
Though generally most pi of use on hands and
knees, the face may be fust affected, as in
Christie's cases, it fades in oidei of appcaiancc
A branny dcsquamation, often trifling, piactirally
always follows it Tins begins in about thiee
days, and imvy persist for se> eral , it is accom-
panied in many cases bj intolerable itching
The eruption usually disappcais in twenty-
foni hours, though it may poisist two 01 three
days, and fevei, if present, is likewise transient
and very slight
At the commencement of this stage, swelling
of tho cervical, inguinal, and axillary glands not
uncommonly occuis, if it has not done so befoie
At Zanzibar the occipital glands woie always
involved. The alicady noted buccal congestion
and swelling of joints may also makt their
appearance now, and lately, ptyalism, oichitis,
01 angina
Vanetiet occur in sopaiatc outbioaks and
different localities, the cases diftcimg in severity
and in the period of incidence, relative piouii-
nence, or oven existence of certain featuios, such
as swellings of joints and glands, pains, haumoi-
rhagcs, eiuptions, or the occiurence of i elapses
For instance, in Calcutta, in 1853, the
characteristic pains weio infrequent, and the
buccal mucous membiano was prominently
involved
In mild cases, too, the course may be very
short and all symptoms absent, except pcihaps
slight fe\er and eruption
Tiue relapses oceui, sometimes due to indiscre-
tions in diet 01 exposure
Serious complications, excepting rare hvper-
pyiexia and mild inflammation of serous mem-
branes, are haidly ever seen unless fiom pievious
disease
M&fite/ce — With desquamation the pains may
vanish, but in many cases they persist in one
or more joints and adjacent tissues, or perhaps
return after an interval of days or weeks They
often trouble the patient for a considerable time,
possess many of the features seen in the acute
stage, and are specially liable to occur in elderly
people The shoulders, wrists, knees, and feet
arc the parts more commonly involved
Some debility, with antenna and anorexia, is
usual after severe attacks, and insomnia, swollen
glands, and •furunculosis are not infrequent
Bequeltc
DiAGtiosis is only difficult m sporadic cases or
in the piesence of concurrent epidemics of in-
fluenza or ) ellow fever Hamilton West demon-
strates its icseinblance to mild attacks of the
latter, which he considers, however, distinguished
by the diffcient com we, the grcatei frequency of
jaundice, albuunnuria, and haemorrhage, and
absence of the characteiistic eruption
From influenza its distinction, at times a
difficult task, is aided by mfioqucncy ot compli-
cations, the season ot \eai, and the pains, erup-
tion, and desquamation
Some ot these teatuies, togethei with epi-
demic pre\alencc, distinguish it fiom ihcuma-
tism, and, aided by geographical distribution,
from measles and scailatma, while in malarious
countnes bl<xxl examination is \ .tillable for
doubtful spoiadic cases
PROGNOSIS is always favourable, unless in
patients ahoady gieatly debilitated, but by its
effects dengue ma;y predispose to othoi illness
Charles describes a laic peimcious type, with
oedema of lungs, (vanosis, coma, ami hvpci-
pyrevia, as occurimg in Calcutta
THFATMFM'- As the disease must urn its
com so, this must be directed towatds (1 ) limit-
ing its diffusion, (2) avoidance of complications
tud sequehe, and (3) leliet ot s\ mptoms
As complete isolation as possible in cle<m, well-
w aimed, and ^outdated rooms, easily digestible
nutritious diet, a simple diaphoietic, lest and
warmth for all stages will best attain these ends,
but can larely in this disease be thoioughly
can led out I'urgatnes and emetics should,
fiom the disticssmg mo\ement they occasion,
be given only if specially indicated
For high tempeiature, sponging, or, in the
tare event of hypeipyicxia, KC and quinine
hypodenmcally should be made use of, while
gastri* uiitabihty is allayed In ice to siuk,
effervescents, and the usual remedies Quinine
is indicated in cases complicated by malana
An ice-cap and mustard pediluvia arc of value
in relieving headache, 01 antipyrin and phcnacetin
may lx» gi\eu These diugs will also rche\e
the rheumatic pains, others lecommcnded foi
the purpose being belladonna and salophen,
while locally small sinapisms and liniments,
containing chloiofoim may be applied 11
very obstinate, however, opium must be pre-
scribed
Warm baths and camphorated oil help to
allay itching, while debility and antenna demand
the administration of stimulants, iron, and tonics
For the rheumatic sequoltc, tonics, sahcylatcs,
and potassium iodide, with massage and faradism,
have been advocated Complete change of climate
may be necessary
DenidatlOn. — The separation of the
superficial part of the uterine mucosa during
menstruation , it is then supposed to break down
and be thrown off If, on the other hand, a
fertilised ovum is implanted on it, it forms for
the ovum a nidus or nest, and glows into the
decidual membranes
DENITRIFICATION
303
Den It r If! cat Ion. >s'«? MICMO-OW.AN-
in (Fermentation nnd Putt ef action)
Den man's Spontaneous Evolu-
On. — A sort of natural version occumng at
above the brim of the pelvis in cases of
insvcise presentation , often contused with
wglas' foiui of spontaneous dclrvciy See
iHOUR, DIAGNOSIS AM) MECHANISM (TmHWetSC
ei, S/ioHttinmut De/meiy)
Dental Caries. *sw TKFIH
'?ffl) ,S'«? fltw NOht, AwKhSOKY Si SUM"-,
H.AMMAT10N OF (Etlo/O(/l/)
Dental NecrOSiS. >SW T*MII (Dental
Dentals. >^' PiiYhinixx.Y, HKMMKAIION
Iw/rv, fyitechf Cotitonant tfountti, Denta/i)
Dentate Nucleus. ,v*r PHYMOHM.Y,
ruvoim SYSIKM (CeifMlwm, NtiuctiiH.)
Dentifrice. — A subsUme, usually .1
wclcr (01 a li<]uul), used foi cleansing the
•th Nff TFhiii (Dtnttil Cm irg, 1'ievention)
Cyst.— A cyst contnin-
% teeth, a tlci moid c^st /NY* MOLIII, Pis-
hfcS 01 1IIK J \W (7V////OM7S O/1*^ A/?/1)
Dentine. ^'« T* M u (</f »rsi s «^ th* '/'< • th,
r at me)
Dentistry, Mechanical. >W
SK1H (Meilvmintl Dentikhy)
Dentition. The cutting (01 eruption) of
u teeth, 01 teething , the nuinbei, chaiactei,
id tiiiaiigeineiit of the teeth, often expressed
-
1 _ -i
_
a formula,, thus — muisois ^ — ^, canines
2 - > \ _ ;j
cuspids 0_0i »iol.us 3_.^ ,SVe»
KVhixiPVRXT OF (Denttttont tiymjttttw*, Timt-
eilt) , (fASIKO-lNTBSIINAL J)lM)lll)fcRs OP Is-
LNCY (Atfmentitif Dentition) , KirKhis(^ViNffff/
entities), 8\r]in is (/;/ C/uhhent Lttfet X/yw«) ,
Bhru (Genew> of the Teeth, Ei upturn)
Denture. ~A set of artifici.il teeth
DeobStruent.— A medicine or substance
hich can remove obsttuctioii by opening tlie
itural passages or pores ot the body, try a
laphoretic or dnuetic dni|;
Deodorants.— Subatant en which dcstioy
ml odoms 01 fetid effluvia , fleodorisei s , they
re not necessarily antiseptic, but many anti-
>ptics aie also deodoiants »Sce DISINFECTION
Deodotants)
Deodorising Liquid. *SV* BURNETT'S
'LUID
Depilatories. — Agents or substances
for removing growing hairs, enpecially hairs
growing on unusual places, eg on the dice in
women, caustic applications have been com-
monly used, but electrolysis is the best method .
the icsults iiom the use of the X-iays ha\e not
aluays been satisfactory A'w X-l?A\s (Hyj>n~
') it host*)
Depletion. — The lehering of plethora,
congestion, or the overcharged vessels oi the
bo(h In medual means, ioimeily (espeeiallj)
b\ bleeding
Depopulation.— l>e( reuse in the pojni-
lation ot a country either because the death-rate
exceeds the buth -late, 01 (less correctly) on
account of aitue eungiation Xre DWI.IVK OP
I UK I'.llUH-lUlE
Deposit. — A sediment in a licpnd (e q
urine) or a substan<e (geueially abnoimal) found
in some oigan or tissue (e >/ uiatie concietions)
tier [ KINL, PAIUOI O(.l( M< (1lf\\(il!,S IN (( 'utility
tfHtUHfHtv)
DepreSSlO. >W C'.OITIIINC. — The sink-
ing ot the lens \\ith its capsule into the vitieous
humoui l>y prcsMiie \\ith .t needle in (ases of
(at.iuu t
Depression. — A loxvoied state of Mtality,
physiological or psychical , also the displacement
unsaid touaids the cranial c.\\ity oi a fiactured
ciamal bone, etc
Depressor Nerve. — The superior
taidiae branch of the vagus nerve , stimulation
of the upper end (aftei section) causes sloxving
oi the heait (a ieile\ effect through the inferior
caidiac blanch) and lowciing of the arterial
blood piessuie See PmMOTtxA, (1IKTUI ATIOW
(Pht/wtlfit/v rtf the J/eatt j\Y/?'OMs (JoHne<tions)
DeradelphUS. — A double monster \\ith
a single head , the tt links aie fused from the
neck dounwaids, raie in the human subject,
less late in animals
Derbyshire Neck. — Uoitie »sw
TH\KOH> (JLAND, M&nrrAij (froitte)
Dercum's Disease.
OUESITV
Derencephalus. — A vanety of the-
tcratological stite known as anencejdial u*, m
>\hich theie m spina bihda only in tlie cervical
region
Derivatives. — Medical or therapeutic
means by which (it is supposed) a diseased state
(such as inflammation) may b? transferred
(draw n a\\ ay) from one part of the body (where
it is a cause of great danger) to another part
(wheie its action is less senous) , blisters, cup-
ping, leeches, etc , are examples of deiivativos.
304
DERMACKNTOR AMKRICANUS
Dermacentor American us.— A
variety of tick or nodes found oc'c.isinnally in
hones and oxen *SW Sc \wiis (Ot/u/ Ainu,
Ixotfa)
Dermamyiasis LI near is Ml-
ffranS OEstrOSa. ,SW OHMTINU Eim-
T10N
Dermanyssus Avi u m. .sv r SCABIES
ou THE Iirii (Ot/tct Acan, Dn Vngeluuitx)
lff la. — Cutaneous nemalgia ,
hypcuesthesia of the skin
Dermatauxe.— -Hypeitiophy <„ thick-
ening of the Hkin , dei matolysis
Dermatin. — A piotcctnc application,
t>aid to consist of sdlicylic acid, kaolin, staich,
tali, and silicic acid
Dermatitis. *'«• HHU>ES (/>W//W«H<,
Dt / Mtitttf S Ifa/M tlJOt fill ?) , M I< 110 - Ol<f i VN IhMS
(/>/ s«f vs f Det tiviti tn Ei toll att w Ifi'tttoi tot wn ) ,
PBLI<A(iR\ (Mymptoin^ Ditttmtitt*) , 1'hMlMUM.s
(Ettotw/y «W /'at/io/oi/i/, Dnit/twiis fiont Oft-
mat it it JfftjMttfmutti) , PKLIINANC\, ArmrnoNs
AVI) COM IM.If \TIONS (ftHJutu/O Htipt'tlJOt Illis) ,
PSORI VMS (Dutt/HOVI flOIH MfMtrthlHt Dtl UHltttll),
SKIV, live rKRioi (Mil OF (Mxmlvm Detuuttiti*) ,
Sii'iliMN (An/mini, tfcionrlfiiy, Aftitnmt of ttu
>S'X/w)
Dermatitis Exfoliativa Neona-
tomm. - V disease1 of the bkin OLCIUHHI? in
the second 01 thud week of lite, cli.uacteiised
liy c\ceM»\o and ^eiicial (i.uoly lnc.il) desquama-
tion of thc» cuticle , Rittet's disease , keiatolysis
neonatormn tiec NEW-HORN IN PANT (Dtwv\,
Dttmutttt*)
Dermatitis Her pet if or mis.
TIPES .J04
SYHPIOMS 30"i
Moitmn AN \IOMI \ND PAHIOIXNI\ .106
PROGNOSIS
TREAT MENT
.'107
307
SYNONYMS -Hydio^ Duhrmg'b disease, pem-
phigus piunginobus, dermatitis niultifoinns,
including herpes gestatioms The altcmativr
name, Ilydroa, appeals to the \\nter to present
obvious .idvantageb over the cunibcrbome title
applied to this disease by Dulning, which is,
howcvci, hero employed in at coi dance with
gencial usage
DermatitiK heipetifornns includes a laige
and bomewhat inchoate gioup of vesiculai and
bullous skin ,ei upturns, having close relation-
ships on the one hand with pemphigus, and on
the other \\ith the bullous crythemata. It ib
only within the last fifteen years that the dis-
ease, as now understood, has been generally
recognised <us a bepaiate morbid entity Hebra
certainly observed cases which he icgarded as
\auanth of pemphigus, and Kaposi mam tains
this view even to the piesent day Bazin dimly
foreshadowed the outlines of the group, while a
posthumous paper by Tilbmy Fox, published in
the Amenctnt An /it vex of Dei i/uttoloyi/, cleaily
showed that that distinguished author distinctly
lecogmsed the special dinical featuies which
charactense the dise.ise, many ty]^)ie,il examples
ol \\hich lie had accuiatcly observed It is,
howevei, to Uuhrmg that the cicdit is usually
.iscribed of finally isolating deimatitis h(>ipeti-
fonnis fiotu its (ougeneis, and his admnable
desiiiption, published in 18S4, still holds gcxxl
to <i laige extent and almost justifies the
patronymic; nomenclature freimently applied to
the disease Moie icccntly Hi OK}, of Pans, has
published many elaboiate at tides on the sub-
ject, insisting especially upon the existence of
t\\o scpai ate foims of deimatitis heipetifornns
-the acute and subacute,— but these distinc-
tions aie not admitted by I)uhiing Unna «uul
many othei writeis have combined to cieate a
mass of ill-digested liteiature, out of all projxjr-
tion to the piactic.il impoitance of the subject,
dwelling mainly upon petty details of little
scientific Aalue, asoui knowledge oi the etiology
of the disease —\\huh must always be tho
latioiial basis foi s< icntific classinciition and
dirteientiation — lemanis Mitually an unknown
thing
Theio is much diffcience of opinion as to
what "types" ought to be included under
deimatitis heipetifornns, moie especially as to
the following — (1) hydioa (vel heipes) gcsta-
tioms, (2) impetigo hoipetifoimis, (3) hydioa
vaccimfoime, (4) ll.illopeau'b chronic pustular
dcimatitis in excenti ically progiessive gioups
Without cnteiing into any elaboiate discussion
on the point, it may be said that dermatologists
aie now pi ac tic-ally unanimous m accepting the
first and in rejecting the thiee last as forms of
the disease undci consideration Unna and
Jamieson aie sttongly opposed to the inclusion
of any foim of skin disease \\hich is not essenti-
ally chronic m its coinse, and m this view the
wntcr fully agiecs
The "types " descnbcd by Duhrmg aie gener-
ally accepted, and are as follows — (a) The et i/tJie-
/tt/itow, including the wticanaf forms, (6) the
t'&ttcitlai , or commonest forms, (c) the billions,
(d) the jwpulai, seldom extensive, (e) the
jntttuJar, in which pustules are present from
the first, and which many would classify along
with impetigo herpetiformis , and (/) tho invtti-
Jwm, in which the several foregoing types co-
exist With reference to type (e) Allan Jamieson
has lecoidcd a case m tho International Atlas
of Rare tikni Diieasei which presented features
common to impetigo heipetifornns and dermatitis
herpctiformiH, forming, as he thinks, a connect-
ing link between the two The former disease
DERMATITIS HERPETIFORMIS
305
being now regarded as not essentially connected
with pregnancy or the puerperal state, Jamieson
thinks that its inclusion under dermatitis
herpetiformis would tend to simplify our con-
ceptions
Dermatitis herpetiformis is essentially a
chronic affection extending over several months
or years, with relapses and recurrences at vaiy-
mg intervals, the skin inflammation being a
supeificial one, and the lesions show ing a marked
tendency to " hcrpctiform " grouping, / e for
various vesicles to form closely aggregated on
a common crythematous base In diileient
attacks the type of the disease may vaiy
Itching, burning, 01 pain is almost invariably
present, the first being the commonest form of
dysaisthesia, and often of intolerable intensity
All are agreed that the disease is essentially of
neurotic origin, and ot< ms in persons of nervous
temperament, while a certain propoition of its
subjects become insane Oddly enough, the
general health in mild eases, 01 during the
early stages, is often practically unimpaired
S\ MITOMH — The onset of dermatitis herpeti-
formis is often preceded for several days by loss
of appetite and malaise, sensations of c lullincss
or flushing, and constipation The temperatiuc
may be laised a dcgiee or two before the
cutaneous ri upturn appeals, and there is often
(onsideiablc pruhiumaiy itching stne lewone
After the eruption has appeared these symp-
toms usually mciease in intensity, and seiious
constitutional symptoms may occur, especially
in the billions and pustular toims Such iases
aie, howcvci, certainly infrequent, the geneial
he.ilth being usually but vciy little affected
The rash is always bilateral, and usually faiily
accurately symmetrical , it may occui 011 any
part of the body, but is most frequently ob-
served on the flexor surfaces of the aims and
wiists, on the abdomen and outer sides oi the
thighs The lesions at first consist of rose-red
crythematous patches or shirhtly raised papules ,
these lapidly coalesce to form plaques, which arc
often circular and average about half an inch 111
diametci These ciicular patches or plaques
present a raised red margin, and their centre
soon becomes flattened, depressed, and of
purplish colour, the appearance closely resem-
bling that of the lesions of ciythema circmatum
After a day or two vesicles or bull<B foim on
the spreading margin, some cases thus simu-
lating a herpes ins (Hallopeau) , the vesicles
vary in size from a millet seed to a pea, or may
even become as large as an inch in diameter
In rare cases bull&e may develop in the centre
of the patches, and both bullnc and vesicles may
form independently of erythema On the other
hand, the crythematous patches do not neces-
sarily vesicate or bullate
While the eruption is developing veiy marked
pruritus is almost always present, and ephemeral
urticanal wheals sometimes manifest themselves
As the vesicles continue to appear, the itching
is supplanted by feelings of burning, pricking,
or actual pain, only relieved by the escape of
the fluid contents of the lesions, this evacua-
tion does not, as a rule, occur spontaneously,
but as the result of the nibbing or scratching
of the patient The vesicular contents are
usually clear and serous, hut* may become puru-
lent Contiguous vesicles tend to coalesce, form-
ing irregular, tnultilocular blebs, which assume
a withered, puckered appearance as they begin
to disappear Finally the ciythematous base
upon which the blobs originally foimed may
disuppcai, the surrounding skin showing no
sign of inflammation When the vesicles are
small, and the erythematous base persists, the
lescmblance to heipes zoster is considerable,
and many ( ases reported as bilateral 01 universal
zostei arc undoubtedly of this nature
Appearances such as have l>een described
occur in successive ciops eithei in lapid succes-
sion or at intervals of several weeks, but in any
given case lesions ot vanous ages (wheals,
eiythema, papules, vesicles, bulUe, and scales or
scabs) are always present simultaneously dining
an attack, although one or other elemental
lesion usually predominates As a rule itching
is more severe in the vesicular and bullous
types than in the other varieties of the disease,
and in the vesicular cases the intervals of
quiescence between the attacks are usually
shoit, the duration of the disease generally verj
protracted In the majority of cases only some
macular pigmentation remains after the sub-
sidence, of the eruption , but in exceptional m-
s tames, observed by the wntei, minute, shallow
atrophic pits, herpetiform in arrangement, have
remained as evidences of former attacks, facili-
tating diagnosis in some dubious cases
The bullmi* type is mgnaliscd by the sudden-
ness of development of touud oi niegulai tense
blebs with very little erythema, but minute
^vesicles or pustules and a few papules are
gcneially also present When the blebs burst
or are broken they dry up, foinnng yellowish
scabs 01 crusts, which drop off, leaving pig-
mented patches If blebs appear in rapidly
successive crops, considciable infiltration of the
skin may ensue and subjective symptoms may
be veiy troublesome The general condition
may be unaffected, but there is generally a
certain amount of pyrexia with chilliness and
f lined tongue
The mvlttfarm type is characterised by the
coexistence of the several types aheady de-
scribed, and is undoubtedly the most frequent
and typical form of dermatitis hcipctiformis
No further description of it seems necessary
here, but a word must be said regarding Hydroa
(vel herpes) gcstatioms, which by universal con-
sent is now icgardcd as a form of dermatitis
heipetiformis occurring either dunng pregnancy
or the puerpcnum It seldom appears before
20
308
DERMATITIS HERPETIFORMIS
the fourth month of pregnancy, but after that
date manifests itself with gradually increasing
frequency up till parturition. Fresh relapses
often occur after delivery and throughout the
puerperal period. In some cases seen by the
writer the disease first appeared two or three
days after delivery. A woman who has once
had an attack of hydroa as the result of preg-
nancy almost always has fresh attacks, and
usually of increasing intensity and of earlier
occurrence, with each succeeding pregnancy.
Subsequently relapses usually occur indepen-
dently of pregnancy, and the case becomes
identical in every way with ordinary dermatitis
herpetiformis. The writer has observed one
case of hydroa gestationis recurring in seven
successive pregnancies; the bullous affection
then became practically continuous and uni-
versal; the conjunctivas were involved, then
the mouth and oesophagus were attacked, and
finally the patient died after twelve years' illness
from the perforation of ulcers in the ileum, pre-
sumably of the same nature as the skin lesions.
The involvement of mucous membrane in
dermatitis herpetiformis is, however, of very
exceptional occurrence, in marked contrast with
what obtains in the bullous erythemata.
ETIOLOGY. — That the disease is a neurosis is
indicated by the severity of the disordered
sensations preceding and accompanying it, by
its peculiar paroxysmal course, and by the co-
existence of other well-marked nervous symptoms
in many of the cases. It manifests itself fre-
quently after some mental shock or emotion,
worry, or nervous breakdown, but a considerable
proportion of oases have been recorded in young
adults otherwise in good health. Its occurrence
as the result of pregnancy suggests its " reflex "
origin, but beyond this our knowledge of the
etiology of hydroa is as purely hypothetical as
that of pemphigus and other bullous diseases.
No relationship with gout or renal disease has
been established.
MORBID ANATOMY AND PATHOLOGY. — In
sections from a case of Jamieson's of the ery-
themato-veeicular type there was evidence of the
origin of the vesicles in the upper papillary
layer, although fully formed vesicles of a locu-
lated character were also met with in the epi-
dermis in close relationship to the hair follicles.
Elliot found some association between the sweat
ducts and vesicle formation, and located the
commencement of the process in the rete and
interpapillary spaces. Gilchrist, however, be-
lieves that the upper layer of the corium is the
starting-point, and has found no alteration in
the cells bordering on the sweat ducts. Both
observers found small cell infiltration hi the
corium, wtiich in Gilehrist's case was found to
consist largely of eosinophile cells, and these
had also penetrated to a certain extent into
the epidermis. Leredde and Perrin, who first
demonstrated the abundance of eosinophile cells
in the serum of the bull® and in the blood in
dermatitis herpetiformis, consider it as diagnostic
and as differentiating the disease frompemphigus;
this has been disputed by Neusser and many
other observers, who have found excess of eosino-
phile cells in both the blood and scrum of
vesicles of eczema and pemphigus. The normal
proportion of these cells is from 1 to 2 per cent
of the leucocytes. In a case of Morris and
Whitfield's the eosinophilia rose from 4-9 per
cent of all leucocytes present in the blood at the
commencement of the attack to 12 per cent
when the eruption was at its height. Whitfield
found from 8 to 15 per cent of cosinophiles in
the blood of another case of dermatitis herpeti-
formis, and double this amount in one of hydroa
gestationis. In a case reported by Danlos
eosinophiles were present to the amount of 25
per cent in the blood and 54 per cent in the
scrum of the blebs. On the other hand, Drysdale
showed at the Pathological Society of London
specimens from the blood of a case of true
pemphigus containing 60 per cent of eosino-
philcs, and in which the serum of the blebs was
extremely rich in eosinophiles ; while Peter
contends that eosinophilia is a more marked
feature of eczema than of any of the bullous
disorders which might be classified together as
pemphigus.
The occasional occurrence of associated re-
current hsemo - porphy rinuria, as recorded by
M'Call Anderson, indicates that the underlying
neurosis is probably of a paroxysmal nature.
DIFFERENTIAL DIAGNOSIS. — Many authorities
assert that it is impossible to diagnose a first
attack of dermatitis herpetiformis with positive-
ness, and that a firm diagnosis can only be
established after watching a certain number of
recurrences. This view is not endorsed by the
writer's experience, although the value of the
history of such cases is always very groat. The
similarity of the lesions to those of pemphigus
and erythema multiforme may easily give rise
to errors in diagnosis, especially as a history of
repeated recurrences is common to all three,
although in different degrees. The blebs of
pemphigus characteristically arise upon skin
which shows no sign of erythema, and are not
intermingled with the scattered papules, vesicles,
and pustules so frequently present in dermatitis
herpeth*ormis; they are usually large and show
no tendency to herpetiform grouping, while the
accompanying constitutional symptoms are
generally severe. Itching is a marked or even
predominant feature of the disease under dis-
cussion, but is seldom present in pemphigus.
The therapeutic test is undoubtedly of consider-
able value, as most cases of true pemphigus
yield rapidly to arsenic, which has no beneficial
effect in dermatitis herpetiformis. The alleged
value of eosinophilia as a diagnostic point has
already been referred to.
Erythema multiforme is an acute disease
DERMATITIS HERPETIFORMIS
307
running a rapid course, and usually with char-
acteristic localisation, often also involving the
bnccal mucous membiane Erythema pio-
domiuates ovei \esication, and the lesions nevei
exhibit heipotiioini grouping
The Ilydroa vaccinoformo of Ba/in (Hutehin-
son's sumraci pruiigo) occurH in young pcisons,
and only in spring and summer , its lesions are
confined to the face and other parts exposed to
sunlight, and tend to dimmish with advancing
age , they lea\o indelible pitted scars
Impetigo heipetifoimis presents many strik-
ing points of distinction The pustules of which
the ei uption is composed aie mmuU1, rmliaiy
they form little groups which spread centn-
tugally , itching is generally absent, the
general condition is grave from the Htart, and
death geueially ( nsues in <i few days 01 weeks
Vesicating urticana may also give rise to some
doubt as to diagnosis, but it almost always
occuis in childien, and the concomitant pheno-
mena leadily distinguish it from dermatitis
herpetiforuns
llallopeau's chiomo pustular dermatitis in
•cxccntiically piogiessivc groups is a vciy r.uc
disease, .ill the recoidcd cases haMiig been
obseived in St Louis Hospital, Pans It
appears to be a local pus inoculation of intense
seventy leading to deep mvol\cment of the
skin, whidi becomes much thickened and fun-
gates A case iccoided by Wickham seems to
show that this condition may supcivcne as an
•cpiphcnomen in cases of Dubinin's disease
The points of difleicntintinn from heipcs 01
any foiiu of "ec/ema" h.i\e been sufficiently
dwelt upon m the pieceding poitions of this
aiticle
PiwxiNosis —Although the geneial health may
in many cases of dcimatttis herpctiformis l>c but
little affected, the favomable prognosis attached
to the disease, and considered by Duhimg as
one of its salient featuies, is fai fioin being
entnely justified , the iccoids of fatal eases aie
now by no means rare The disease, as a rule,
ceases spontaneously rather than as the lenilt
of tieatment, aftei lasting for many months 01
years , or a fatal tcsult may ensue fiom ex-
haustion 01 septicaemia Generally speaking,
the erythematous forms and those connected
with pregnancy aie the most benign, while m
the bullous and pustulai forms the piognosis
is moie giave
TiwATMKM1 — (>ctioral, lathci than local,
treatment must be iched upon m the case of
dermatitis herpctifomns The patient's mode
of life must be caiefully regulated and all
worry and anxiety avoided , hence piobably the
advantages denved from a stay in some quiet
country spot or at a spa, eithei British 01 Con-
tinental The best of these are probably Harro-
«atc 01 Strathpeffer, Gastein, Kissmgen, or
JSchmtznach The diet must bo ample and
nutritious, but non - stimulating Alcohol is
ceitamly deleterious in most cases and tends to
inci case itching, the moderate use of tobacco,
on the other hand, appeals often to l>e distinctly
useful Milk is extiemely valuable as a food,
and if well supported should be taken m con-
sidciablc quantities dining the day. Constipa-
tion must be caiefully guarded against, it is
best combated by aperient, bittei, 01 sulphurous
waters taken first thing in the morning, and
prcfciahly warmed The value of arsenic has
been variously estimated , Hutchmson reckons
it as high, but this is not the opinion of the
wntet nor oi the majority of deimatologists
When the eruption is in its early stages it is
certainly ag»iavatcd, like many other skin
affections, by aisemc, but when on the wane it
may perhaps be benefited by the drug cautiously
admimsteied Arguing by analogy it also seems
probable th.it when administeicd between the
attacks aisemc may tend to dimmish the
tendency to i elapses In smnlai cncumstanccs
small doses of iodide of potassium seem some-
times useful In some cases quinine in full
doses is ceitamly beneficial Crock ei recom-
mends the use of full doses of belladonna,
beirinnmt? with fifteen minims of the tincture,
rind mci casing it to thirty minims three times a
day Any evidences of a gouty tendency must
be treated by dieting, alkalies, and diuretics , it
is in such cases that baths die of special semce
To control itching no drugs aie more valuable
than pheiiacetm and antipyiin m full doses
There is no valid objection to the use of chloral
and bionndes to obtain sleep, but moiphia is
decidedly contra-indicated as tending to increase
iriit.it ion A prolonged waim bath at bedtime
containing sulphate of potassium (gij - giv ),
boiax (5iij ), bicaibonate of soda (y\ ), bran,
linseed, or sue (2 to 3 Ihs), in 30 gallons of
watei, with 01 without a little liquor Carboms
deteigens often alleviates itching and procures
a gocxl night's sleep Constant icst in bed is m
itself beneficial, piobably by seeming compara-
tive umfoimity oi tempeiature
Locally Duhimg \\aimly recommends sulphui
ointment, and his opinion is endorsed by Stephen
Macken/ie , it must be vigoiously rubbed into
the skin, the vesicles and blebs being ruptuied
Ichthyol has been warmly .uhocatcd m some
quaiteis , internally in five-giam doses, either as
capsule or pill, mci eased up to twenty giams 01
moie thiee times daily, it is really of service
Tts disagieeahle odoiu rendeis it seldom tolerated
in this countiyas an external application It
may be painted on in aqueous solution from 5 to
25 per cent, 01 applied as a dusting powder or
ointment The following formula? are con-
venient — 9
it Ichthyol, gr \\
Resoicin, gr \
Pulvens amyh
Magnesn carbonatis, aa *ss
Miscc Fiat puhis
308
DERMATITIS HERPETIFORMIS
& Ichthyol
Camphoric, aa gr x
Olci amygdala) dulcis, 3j.
Adipis lance, 53
Misce Fiat unguentum
In the erythematous form, when few 01 no
vesicles are picscnt, diessmgs soaked in the
following aic usctul —
R Resoicm, gr vij
Glycermi, !\xx
Spnitus (oloniensis, ,~ij
Spintuiu vim icctihcati, <ul 5j
Misce Fiat lotio
The w liter h.is found nothing more useful
than weak le.wl, tai, carbolic or naphthol lotions,
but sometimes oily applications containing these
drugs aie nioie giateiul to the patient.
Dermatitis Repens.
A spi coding dermatitis, usually following in-
juries and commencing almost exelusixely in the
upper extremities
Theie is genciallv «i histoiy of .in m]iny to
the skin of some part ot the hand, though often
the injmy may l>o so trivial that its occurrence
may have to be carefully inquired foi Vesicles
or a bulla develop and luptme, resulting in
complete denudation of all the upper layers ot
the epidermis, the surface being intensely red,
and oozing a cleat 01 turbid fluid fiom numcious
points on the suifacc The denudation extends
peripherally by the epidermis at the border,
being undermined and laiscd up by exudation,
forming a sodden ragged collar which can be
leadily cut away, but nevertheless extension con-
tinues, and the disease may travel all up the
first affected limb or stop short at any point
Less frequently it extends acioss the trunk to
the other extiemity 01 rarely all ovoi the body
The parts fhst affected may heal slowly, leaving
the skin intensely red and tender The ex-
tension may be very slow— J to J of an inch a
\vock — and drag on foi many months and even
for years, or the extension may be at a much more
rapid rate The sensory symptoms are burning
and tension rather than itching, and after healing
great and persistent tenderness
A closely allied condition, if not a mere
variant of it, are the cases descubcd by Hallo-
peau, under the title "Aciodeimite continue,"
and by Frcche and Stowcrs, who acknowledge
their resemblance and alliance to dermatitis
ropons, while Hallopeau considers them separate
affections The actual lesions of the skin on
the extremities are practically identical, but
Hallopeau attaches importance to the following
differences In Dermatitis repens the disease,
if it extends*Deyond the hands, does so by direct
extension of the border, while m Acrodermatitis
it is by the formation of fresh foci, and the
large areas are formed by their coalescence
In acrodcrmatitis there is no permanent
healing of the older diseased areas, and the
cases go on for years with little or no improve-
ment The nails are damaged and may be
shed, and the oial mucous membrane may be
affected An antecedent injury has been present
m some but not all of the cases
Pathoijeny —The theoiy most consonant with
the clinical facts is that thcie is a peripheral
ncuntis with secondary microbic invasion of the
damaged aiea, but Hallopeau only .idmits the
niKTobic ongin of acrodoimatitis
Dtagnovb — Kc/ema is the disease foi which
deimatitis repons was mistaken until diflei-
eiitiated by the author The differences ate
the extension at the periphery by the constant
fluid exudation uiidci the bolder, which foims a
well -defined mat gin , the persistence of the
lesions for long periods \\ ith slow but constant
extension, and the difficulty of healing the
denuded suifacc as well as of checking extension,
and the ranty ot the formation of flesh foci of
disease tar away from the original ai ea Further,
for a long time the affection is limited to one
extremity
Treatment — The disease is \eiy rehactoiy to
tieatment, which need only bo local The most
successful plan has been to cut away the under-
mined epidcinns bordoi and paint once a day
foi ten days with a 10 poi cent solution of
permanganate of potash The constant appli-
cation of lint soaked in lactate of lead lotion
(Liq Plumbi Subacet 3j , Lactis 513 ) has also
been successful Hallopeau paints with a strong
solution of nitrate of silvei, but the authoi has
not had a good result with this, and Hallopeau
has only had amelioration and never a definite
cure
Dermatitis Traumatica et
Venenata.
GENERAL CONSIDERATIONS 308
CAUSAL AOEM'H 3091
INFLAMMATORY FORMS 310
SPECIAL ERUPTIONS 312
FEIGNED ERUPTIONS 313
OASES of dermatitis from these causes anse
horn one of thiee circumstances — (1) From
the pursuance of some employment which ex-
poses the patient to the action of tho noxious
agent, (2) From the accidental exposure of
the patient to some such agent, (3) Feigned
eruptions
Putting aside for one moment those sub-
stances which are such powerful irritants 01
corrosives as to cause a practically immediate
destiuction of all tissues with which they come
into contact, there arc some points of interest
common to nearly all the irritants of the skin
as regards their action m producing a dermatitis
The first peculiar point m connection with
occupation or accidental deimatitis is the vary-
ing dcgiee of susceptibility found m different
DERMATITIS TRAUMATICA ET VENENATA
309
people. Thus to poisons which act with the
greatest severity upon borne persons others may
be partially or even completely immune White
relates the case of a child of six years old \vho
died from the effects of severe ivy poisoning
produced by having his skin rubbed while wet
by the hands of a boy who had been rooting up
plants of the poison ivy This case is rendered
still more remarkable by the fart th.it the boy
had previously washed his hands thoioughly,
undei supervision, first with hot soap and watei,
and afterwards with vinegar The boy who
had been working with the plants h.id a full
,iiid apparently peimanent immunity to the
poison
Secondly, some peisons who aie more or less
susceptible to the mitant at first may bo
variously affected on piolonged exposure to its
action, becoming sometimes immune to its
effects, 01 sometimes moic susceptible In the
second case it is, of couise, impel ative that the
mjuiious occupation be cntnely given up foi a
time, and if aitei a complete recovciy the
patient retains to hw employment, he may be
attacked again cither at once or after a long
period of immunity For convenience of de-
scription the foims of dermatitis may be
divided into —
(1) Ooriosion of the skin with formation of
slough, due to veiy acti\e chemical substances
(2) Acute inflammations of the skin usually
resembling acute eczema, but in some instances
restricted to an in ticai lal oedema
(3) Chronic tonns of simple dermatitis which
are quite indistinguishable from chronic cc/ema
(4) Moie 01 less charactenstic eiuptions not
resembling eczema
I The agents producing deimatitis of this
variety aie The stiong mineral acids and the
caustic alkalies, and some metallic salts, such as
•/me chloi ide, etc The contact of such compounds
with the skin is usually the icsult cithci ot
accident or design, since it is obviously impossible
that any employment could be followed which
entailed constant cxposuie to the action of siuh
desttuctivc substances In the case of the
at ids the effects are usually moie cncumscribed
than in that ot the caustic alkalies, owing to
the fact that they all cause a coagulation of the
tissue albumins and so are inoio or less self-
limited In all cases the result of the action is
to cause a slough sui rounded by an aiea of
intense inflammation After sepaiation of the
slough an ulcer of vaiying extent and size is
left, which is usually slow to heal, and has a
special tendency to leave an hyportrophied scai
The reaction of the slough is naturally intensely
acid whore caused by the jiction of the strong
acids, and in the case of nitnc and sulphuuc
has a yellow coloui, moie pronounced in the
case of the former than the lattei The slough
left by the action of the caustic alkalies is of a
less hard consistency, and is, of course, strongly
alkaline in reaction The colour is usually of a
dirty greyish white
Tteatment should be directed towards the
free dilution of the poison if seen early enough,
and the initialisation with a substance of the
opposite chemical icaction After separation of
the slough the i esulting ulcer should be dressed
with some bland ointment, such as Listei 's boric
acid ointment
II The agents causing acute dermatitis of
the second class may be divided into —
(«) Annual — Jellyfish and allied species,
li.uiy catci pi ILu s and stinging insects, such as
hornets, wasps, bees, etc, which all cause
ciuptions oi the mticaiial type, the silk in
cocoon, which causes an irn table eczema-like
eruption on the hands oi the winders, and
can thai i<le->, which causes bullo1 if in strong
concentiat ion, or a peculiar pustulai eruption
with haul papules it constantly lepeated in
we.ik stiougths
(b) Vi ijetable — llh us tout odendi on, \ enenata,
diversiloba, and \eimcifeia, the fust three
generally accidental, the last occumng in the
piocess of the manufactuie of Japanese lacquer,
and occasionally in the handling of the finished
article , primula obconica, cheriy lain el, aucuba,
ainica, jumperus sabina, staphisagna, capsicum,
pi pei nigra, oil of cioton, mustaid, tuipentine,
and thapsia The abo\e list, which docs not pie-
tend to contain the name ot every vegetable sub-
stance causing deimatitis occasionally, includes
those that are most likely to be met with in
practice Hi sides these there arc many mcm-
beih of the family Uitieaceie, as instanced by
the common stinging-nettle, which produce fin
uituanal eruption
(() Chftnual Compound* — Ccitain aniline
dyes, as found in clothing, said to be due in
e\eiy case to arsenic as .in impurity, but piob-
ably oitcn due to the moidant, which may be
aisenic or potassium bichromate In this con-
nection it may be mentioned that a \eiy seveie
eiuption was found on the arms of some woik-
mcn, and tiaeed to the presence of zinc chloride
in the clothmg Autnnonial salts cause an
acute papulopustulai eruption, but this is not
often m«»t with now except in the case of
feigned ei options Toilet articles and cosmetics
ha\e been not mfiequently found as causes of
an outbreak of cczcmatoid ci upturn, especially
hair djes which contain pyrogalhc acid or
nitrate oi sihci Neisser traced scveial cases
of obstinate eczema ot the lips to the use of
a dent if HOG containing many atomatics and
some salol Pyiogallic acid is sometimes also
the cause of ei upturn on the hands of photo-
grapheis, but as they aie oft$n handling
numcious othei chemicals, it is dimcult to find
out exactly the cause in any given instance
Phenyl hydiazin has lately been found by a
chemist expciimentmg with it to give rise to a
veiy acute \esicular eiuption resembling eczema.
310
DERMATITIS TRAUMATICA ET VENENATA
Lastly, many substances used in surgical
dressing are apt to cause ouuto deimatitis,
such as lodoform, carl>olic acid, and collodion,
which last sometimes causes bhhteis whcicvei
applied.
(d) Phywtl Af/enctes — X-iay* (s«- " \-
Rays")
The ci upturns belonging; to this class fall
into two sulxiivisions, namely, the mticaiiul 01
oxlematous and the tine inflammatory An
types of each lespectively the lesion pioduted
by the common stinging-nettle and that pio-
duced by one of the poisonous plants, Uhus
toxicodendron, will IK* desuibcd
A The 1<n met needs only the t»hoi test notice,
as the rash is almost alwajs quite e \anesccnt in
character It must not be foi gotten, ho\vcvei,
that in the case of some of the tropical plants
the effects are much moie lasting and seveie,
and that with some of the jellyhshes ei upturns
have occurred which, although beginning as
urticana, ended with gangicne The symptoms
of the uiticanal class aie then, hist, shoitly
after the contact with the poisonous body, a
circumscribed hypenemia of the irritated spot
associated \\ith shaip binning In a few
moments there occurs an exudation of serum
into the hypersemic aiea, with the lesult that a
pinkish spelling is piodnccd which changes to a
yellowish white as the tension in the osdcmatous
papule is gradually raised, and the capillaiies
are closed by the sui rounding pressure Aftoi
remaining in this state foi some time, usually
about half an hour, the exuded scrum becomes
gradually reabsoibed, and nothing lemams but
a slight passive hyperccmia to niaik the spot
where the reaction occuried If the lesion is
situated on some spot where the subcutaneous
tissue is very loose, such as the eyelid or
sciotum, the swelling IH apt to be vei} much
gi eater and may completely close the eye
Tteatinent consists in the application of evapor-
ating lotions if the pain is ^ery seveio
K The acute fcrenuitmd do matitn commences
as a local hyperiumia 01 eiythema of varying
extent Compared with the ciythcmatous stage
of so-called idiopathic ec/cma this traumatic
erythema will be generally found to he more
brilliant in colouimg and moie acute in onset,
thus resembling erysipelas In some cases the
disease may go no faithei than this, the hypei-
tcmia subsiding aftci a few hours, and leaving
nothing behind but a slight yellowish dis-
coloration due to diapedesis of red blood-
corpuscles, to bo followed by an insignificant
dcsquamation of the damaged epithelium. Moie
frequently, however, the hypenemia is rapidly
followed by^ serous exudation into the conum
and, later, into the epidermis itself This is
shown clinically by a marked thickening and
swelling of the skin, accompanied by oblitera-
tion of the normal folds, and by a slightly
translucent appearance in those situations where
the skin is thin and the subcutaneous tissue
loose, such as the eyelids, penis, and scrotum
After the exudation of scium has gone on for
a ceitain time the fluid begins to pass upwards
into the epideimis, distending the mtci cellular
canals, ruptnimg the connecting piickles, and
pushing aside the cells of the mucous lajei so
as to toim small vesicular cavities Most of
the vesicles thus foimed buist, either fioni
piessure of the contained fluid 01 fiom exteinal
violence The condition then found is one of
intensely inflamed skin coveted only by the
moist layein of the epideimis and fieelv pouring
out a straw-coloured fluid whuli dues into
gummy ci usts on the suiiare If the skin be-
no furthei exposed to the action of the mitaiit
the exudation of fluid gradually diminishes
until it ceases altogethei, a new homy lajei IH
ioimed, and the surface i-iadually ictuins to
the noimal Fiequentl) the exudation into the
mucous layet is so lapid as to KUSO the hoin}
layei in laige aieas, and then bulhe aie the
lesult, 01 in other cases wheic the imtant
causes a maiked emigiation of leucoeytes, the
vesicles may become quite cloudy and pmulcnt,
notably so in the cases of antimomal salts and
iioton oil In some cases, again, the inflam-
mation may become so intense as to cause death
of the tissues of the papillaiy layer, in which
case nlceiation will tike place, and the disease
can only tei inmate by the formation of a scat.
This, it should be noted, howcvci, is by no
means a fiequcnt occimcncc in the acute
ec/ematoid foims of deimatitis, but is much
moie often found in the moie chiomc cases of
nutation by some active chemical agent As
logards the dm at ion oi the acute foims of
deimatitis no exact time limit ran be given
The effects of the poison may bo limited to a
slight and evanescent u-dncss which passes oft"
within a low hours, 01 thcic may be considei-
ablc exudation with vesule formation, m which
case recoveiy will be unlikely to be complete in
less than a fortnight, 01 if the disease i caches,
a high degiee of seventy, e\en without ulcei.i-
tion, it will geneially last seveial weeks
In addition to this, one must remembei that
some cases of appaicntiy simple acute Uaumatic
deimatitis do not recover of themselves, but
aftei some improvement has taken place tend
to pass into a chiomc state which is entnely in-
distinguishable from chiomc, idiopathic ec/ema
The subjective nyn^toinx of .acute traumatic
deimatitis are in no way characteristic, but aie
simply those of acute inflammation of the skin,
the affection usually beginning with tingling
and itching, which is followed by a more or less
severe burning and itching as the inflammation
pi ogresses to its height
The diagnosis of acute dermatitis fiom acute
ecrcma is apt to bo extremely difficult or
impossible The site and histoiy are important
in every case The sites most usually affected
DERMATITIS TRAUMATICA ET VENENATA
311
arc — The hands and forearms, the face,
especially round the eyes, the neck, the scrotum,
and the inner side of the thighs The reason
for the localisation on the hands and face is
obviously the greater iiequency of exposure of
these paits, while probably the scrotum and
thighs are often attacked fioni the extreme
delicacy ot the skin of these paits, so that any
chance contact with hands covered with the
irritant is almost mire to pioduco the eruption
The piognovn of the acute forms of dermatitis
is almost mvaiiably favourable, though cases
have been known where death has ensued,
probably from absoiptum of the poison through
the hkm, denuded as it is of its protective
horny layer
The tt&tttnenf should be th.it for any ex-
tremely acute milaniination ot the skin Steps
should be taken to pi event any further ex-
posure to the influence of the uritant If the
eruption is extensive and severe the patient
should be kept in the iccumbent ix>stuie,
so that the en dilation may be rendered as
quiet .is possible, and only a light diet should
be allowed No internal treatment has any
direct action on the course of the eruption, but
it may be of advantage* to give a dose of calomel
at the commencement ot the attack, as this will
at least tend to expedite the excictiou of any ot
the poison which may have been absorbed
Locally, lotions ai e of most service in the
eaily stages, such as diluted black-wash, lead,
or calammc lotion If itching is scveie a vc-r^
small peicentagn ot carbolic acid may be added
to the lotion In the United States and Canada,
whete the disease is of much moio common
occmreiue than in this country, owing to the
greater prevalence of poisonous plants, the
thud extract of Ciindoha liobusta, diluted one
in Unity, is in gieat repute Aftei the cessa-
tion of the dischaigc and the moie active
symptoms ot inflammation, recourse may be
geueially had with advantage to bland pastes
or ointments, but in no case must any stimu-
lating application be used unless thti eruption
shows signs of becoming chiome One ot the
best soothing and protective applications will be
found to be a cieam made up of equal parts of
zinc oxide, almond oil, and lime water, with
htteen grains of anhydrous lanohne \ to each
ounce of the mixture This application is
cleanly, and is also cooling from the evaporation
of the water, while it contains just sufficient
grease to soften the inflamed skin and render it
supple, thus obviating the uncomfortable feeling
of stiffness and the liability to hssure which are
apt to be present owing to the insufficiency of
the homy layer
111 CHRONIC DBKMATITIH — This is caused by
the prolonged action of substances either of
less virulently irritating properties or m a
greater state of dilution than those which cause
the acute forms of dermatitis The offending
body may act simply tnechanically, as in the
case of fine powders, accounting for the rashes
found in potters due to the fine clay, in mill
stone and quairy cutters from particles ot
stone, in glass-paper makers, pearl cutters,
knife and needle grinders, etc Or the sub-
stanee may be irritating both meclumicnlly and
f/ieunrally, as the hnely-poVdered sugar which
irritates the arms of grocers, or, lastly, the
unUnt may act chemically only In this last
f lass the offending agents are almost innumer-
able In contiadistmction from the acute form
of deirnatitis the chronic form is almost con-
fined to people whose pursuits bring them into
daily contact with the offending substance
The commonest cause of all is the constant im-
nwrsion of the skin in water containing an alkali,
such as is present in most soaps Another
very frequent cause is the washing up of
utensils which contain decomposing alcohol and
v\eak acids, such as are found m the dregs of
beor and wine gln,ss(s, hence the disease in
barmen and waiters , also in cheap methylated
spirit, such as is used in dissolving varnishes
Repeated contact with most metallic salts m the
moist state will m time irritate the skin &o as
to produce a (hronic deimatitis, and hence
anses the disease known as galvamser's ec/ema,
due generally to the ammomo-mckehc oxide m
the hath Almost all the aromatic oils and
perfumes aie capable of inducing a chronic
dermatitis w hen constantly used, and are gener-
ally found in face washes, powdeis, etc- Also
many (hugs aio responsible for eases of skin
disease in those who prepaio them, instances
being quinine, aconite, podophyllm, i ue, vanilla,
and oil of bittei orange
Chronic dermatitis tiom any of these causes
is usually of the diy hchenoid type The skin
is diffusely reddened and infiltiated the cpi-
deimis is thickened generally , is of a harsh, dry
character, and contains much less gicase than
normally Consequently the normal folds of the
skin are much deepened, and are apt to form
tioublesomc fissures from the want of elasticity
and proper cohesion of the diseased homy layer
The mouths of the follicles are often slightly
gaping and hyperkeratotic, and the lanugo hairs
.ire stunted and broken Vesicles are found here
and there from time to time, and are usually
situated rather deep down m the epidermis
Secondary p>ogenic infection of the fissures IB
very common
The ei upturn is apt to spread beyond the
points of actual contact with the uritaut, and
this fcict has given rise to much discussion.
Some observers hold that this spreading beyond
the actual points of contact is proof that chemical
irritants can call forth a true eCzcma, while
others contend that the spreading is caused by
the inoculation of the eczema virus upon the
already damaged skin Be this as it may, it is
found that chronic dermatitis from external
312
DERMATITIS TRAUMATICA ET VENENATA
irritants is almost invariably symmetrical, that
it often lasts long after the cause has been
removed, and shows little or no tendency to-
wards spontaneous recovery, and that it is
especially liable to attack the sites of predilec-
tion of idiopathic eczema
The treatment of this form of eruption is of
course primarily to remove the source of irri-
tation Aftci this has been done it will be
generally found necessary to apply some bland
emollient preparation foi borne time until the
more actively inflammatory symptoms have sub-
sided and any fissures present have healed One
may then proceed cautiously with some weak
form of stimulant of the ( lass known as reducing
agents, and perhaps one of the best will be
found to be Pick's salicylic acid soap plaster,
which should be spread rathei thickly upon old
coarse linen, and kept continuously applied day
and night The geneial principles of tieatment
of chronic eczema apply equally well to this
artificial dermatitis, and need not be gone into
in detail
IV. The fourth class of ei upturns, those thai
are more 01 less characteristic, contains only a
few members
The first gioup consists of those caused by
arsenic*, antimony, potassium bichromate, and
potassium cyanide The first three of these
drugs may all of them produce an acute cc^cma-
toid dermatitis, though Richardson stated that
potassium bichromate had no action on the
sound skin The feature common to them all,
however, is that they arc liable to produce veiy
obstinate ulceiation if they come into contact
with even the slightest abrasion of the epidermis
The first three substances arc all occasionally
used, cither in the preparation or the mordant-
ing of aniline dyes, and potassium bichromate
is also present in certain kinds of wood polishes
Potassium cyanide is used by photographers, but
on account of its known poisonous action its
effects upon the skin are less often seen owing
to the care with which it is handled
As regards the diagnosis of these eruptions
arsenic should be suspected if there is either
digestive disturbance or inflammation round the
eyes, while bichromate stains the nails and skin
a characteristic yellow colour There are no
special characteristics which would enable one
to diagnose the presence of the other two
poisons.
A very characteristic eruption is seen on the
skins of tar workers, and probably the same is
caused by allied substances, such as paraflms
and soot, owing, in the case of the last-mentioned
substance, to the traces of coal tar contained in
it The eruption appears on places where the
skin is broifght into contact with the offending
substance, in the case of the tar worker hot
anthracene oil, or more rarely creosote oil It is
greatly dependent on the habits of personal
cleanliness of the individual, those who take
care to thoroughly wash off all traces of the
irritant on leaving work suffering very much
less than those who are careless in this respect.
The sites of predilection are the face, especially
the hairy parts, the backs of the hands and arms,
though occasionally sparse lesions are found on
tho palms and the scrotum
The earliest lesion appears to be tho plugging
of the follicles with inspissated tar prcxluctH
The irritating action of this obstruction, prob-
ably partly mcchanicMl and partly chemical,
causes a rapid overgrowth of the cells around
the follicle, so that the mouth now contains a
blackened horny plug Bclou this suppuration
may occui, 01 the plug may be detached by
simple mechanical movements In either case
a small dcptesscd seal is the lesult, so that the
arms have a honeycombed appeal ancc, especially
when viewed in .in oblique light Besides these
scais, however, thcic arc always present numer-
ous little horny plugs which have not become
expressed The han is usually maintained since
the destruction IH too supcihcial to affect tho
bulb Associated \\ ith this staije of the eiuption
is also a scries of red and veiy slightly thickened
s{K)ts, which aic seen undei a lens to consist of
dilated blood-vessels, and aie, in all probability,
duo to tho repeated hypcitunna fioiu the splashes
of the hot oils At all events these hypercemic
spots aic not acutely inflammatoiy since they
last for ye.us In some cases the follicular plugs,
instead of being removed by suppuiation 01
otherwise, grow to a considerable size and then
agglomerate to foim the so-called tai mollusca
It is plain that there must be cousideiahle pro-
liferation from the first of the cells at tho mouth
of the follicle, in order to produce that hypcr-
keratosis which is one of the eailiest appeal anccs.
Later this pi ol if oration appaiontly aflects the
deeper cells, and then these grow out sideline
beneath the surrounding epidcimis so as to pro-
duce a hard base and a peai ly edge, thus com-
pletely simulating i orient ulcer The growth
is, however, not yet malignant, though at any
moment it may become so, and in most cases if
loft alone will slough out, leaving an ulcer which
heals and produces a cribriform scar not unlike
that left after vaccination At the same time,
in addition to the molluscum form of tumour,
there is another, the common flat wart, the
evolution of which is not quite so clear On
examining the affected skin m early stages, how-
ever, it can be seen that there is general hyper-
keratosis of the parts between the follicles,
though not to so maikcd an extent as of the
follicles themselves, and it is probably from this
intcrfollicular skin that the common wart is
developed These waits may also become the
seat of malignant disease, taking on the charac-
ters of true epithehoma It may be lemaikcd
that, in the case of sweep's cancer of the scrotum
recently seen by the writer, a careful search
revealed the presence of very numerous small,
DERMATITIS TRAUMATICA ET VENENATA
313
flat warts on the ulnar borders of the flexor
surfaces of both forearms
The treatment of this affection should be in
the fiist place of a preventive kind The men
in tar works should be pioteeted as far as
possible from the splashes of the hot liquids,
and should be in all cases encouraged to observe
sci upul OILS cleanliness aftoi cessation of wotk
As repaid s curative treatment, when the erup-
tion has once developed there is little to be done
at first The workmen all know themselves that
if they pick off the little homy piojcctions they
aie liable to aggiavatc the disease If anv of
the turnouts grow to an iiieom omont «*i/e it is
advisable to KIUOM- them without waiting foi
exfoliation, .ind in any case a shaip look-out
should be kept on all growths, so that, should
any of them develop malignant tendencies, they
may be lemoved at once
As has boon abeady noted, a rash strongly
icsembling that just descubed has been obsei ved
in woikeis \\ith paiaffm, though this agent docs
not appear to pmlme the epithelial tumours
Theic is, howovei, anothei foim of eruption
occasionally seen on the legs of those men who
habitually carry about vessels of peti oleum
Usually the light leg only is affected, owing to
the iact that the can is can led m the right
hand The right trousei leg g« ts satin ated with
the oil, and its action, aided perhaps by the
constant inctiou of the skin, pioduces a curious
bullous ei upturn situated on a bi iwuy and in-
flamed base There is usually a considerable
amount of pyogenic infection of the eruption,
which soon (lies away undoi soothing and pio-
teetixe pastes
Kecently a chemical much used as a developer
of photogiaphie plates, tnftal, has been found to
cause a somewhat chaiacteiistic eiuption on the
hands The salient features of the eruption
are — A stiikmgly polished appeal ance of the
cpuleimisas if \aimshed , a diffuse, even, cyano-
tic hyper«emi«i of the affected parts, almost blue
in (oloui , thickening of the skin itself, with
the subjective symptoms of numbness, stiffness,
itching, and pain The eiuption somewhat
resembles both permosis and ciythromclalgia
Fiom the foimer it is distinguished by its ocuin-
rence in hot we.ithor and its affecting all the
fingers evenly, while from the latter it may
lie easily differentiated by the absence of the
c hai actei istic paroxysms of pain Recovery takes
place in two or three weeks aftei removal of the
cause
Feigned JStujttiom — Lastly, a Blunt descnp-
tion must be given of the ieigned eruptions
These have been separated from the mam tnxly
of artificial eiuptions — first, on account of the
fact that they are not all ti ue inflammations ,
and, secondly, because they present some peculiar
features of interest There aie two classes of
case to be considered— that in which the erup-
tion is pi od need for obvious reasons, such as
to avoid some distasteful occupation, and that
in which there is a morbid state of the mind
Patients belonging to the second class should
always be most carefully watched for symptoms
of mama developing Thus in one of Shepherd's
cases a girl ran out of the hospital waid, whcie
there was no fire, with her clothes on fire
T/te type* of eru/tttfjn may be divided into
anomalies of seootion, such as red and black
sweating, blue concretions at the mouths of the
oebaceous follicles, etc , and inflammatory ci up-
tions
lu the former class the number of colouiing
agents which may be used is almost unlimited,
though curiously enough soot seems to be one
ot the most favourite applications The pig-
i )cnt i* generally made up with grease to make
it adhere -propcily, so that a few drops of ben/me
on a tuft of cotton-wool win '-lean it off, leaving
i peifectly noinul <»kin beneath The differential
r/trfr/MOw< of these eiuptions from those of true-
coloured secietion is Aery difficult, and is only
to be accomplished either by caieful watching,
01 m those instances in which the substance
used can be identified by chemical or micro-
scopical examination, as in a case in which
extiact of liquoiiee was used to simulate bleed-
ing points
Jn the nijlantmatoty class of cases the ciup-
tion may be simply a hypeitemia, or it may be
nioic often bullous, vesiculai, and pustulai, with
gangicnc and ulceiation, or again it may
be some deep- seated chronic inflammation of
nodulai charactei Often there is, as in other
kinds of hystciical manifestations, some tiue
lesion of the skin 01 some eiuption produced for
theiapeutic purposes as the iorcruuuei of the
feigned manifestation Thus some patients who
have been tieated by bbsteimg by one doctor,
have aftciwaids pToeuied pieparations of can-
tharidcs with which to deceive people Some of
the substances used have been nitric acid, car-
bolic acid, can thai ides, croton oil, taitar emetic,
and mustaid The circumstances which should
al \\ays give use to suspicion aie mcoiiigible
idleness in men, hysteria in women and girls,
the age of pubeity, the correspondence of the
eiuption with no known form of idiopathic eiup-
tion, combined with a similanty to the effects
of known irritants, and the occuncnce on the
left side and on situations which are easily
leached by the patient In many cases the irri-
tant will have run on the skin, pioducing a
streak below the pitch of inflammation, and the
patch itself has often niegular outlines In
doubtful cases the litmus paper should always
be used, as a veiy stiong acid icaction of the
tissues will remain for days when any of the
mineral acids have been used Sometimes the
patch may smell of the corrosive, as in one case
wheie the slough was produced with ciude car-
bolic acid used for disinfecting purposes Lastly,
the aiea, if showing the ch ionic inflammatory
314
DERMATITIS TRAUMATICA ET VENENATA
form, may be carefully wiped with a pledget of
cottonwool soakod in soft soap and water, and
the material thus obtained tested for arsenic
and antimony Cioton oil, one of the favouutc
applications for producing feigned eruptions, is
not easily identified chemically, and its use can
only be suspected by the presence of its pustular
eruption on the skin and by careful search of
the patient's belongings Othci methods of pio-
ducmg curious eruptions are by f notion of the
moistened skin, sometimes after pievious pro-
longed sucking ot the pait, thus producing an
excoriated whcal, 01 by the application of heat
foi so shoit a time that no true bulla tommtion
is produced, but a'supoifieial destruction of the
epidenms with subjacent hypeicCima Many
cases of spontaneous gangmic of young \\ornen
have been published on the Continent, but on
leading the repoits of these case** the writei is
convinced that most, if not till of them, >\eie
really instances of feigned eruption
The treatment in all doubtful cases should be
the care tul diessmg of the affected pait in such
a manner that the patient shall be unable to
get at the place In such cases the ci upturn
has often been found to occui named lately
beyond the dressing, a fact which, if icpcatcd, is
practically diagnostic Exposure ot the patient,
when detected, is not always satistactoiy in its
results, since it is usually impossible to con-
vince the relations, and the patient only gets
moie sympathy Sometimes the patient hci-
sclf can be quietly lectured with better lesults,
but it is probably always better to put her
under a ngid course of tieatment directed
against the mental unsoundneHS
Dermatitis Traumatica et
Venenata In Coal-Miners.
Introduction 311
A Phytical Cauve* Division —
(1) Intertngo 314
(2) Eczema oi the External Audi-
toiy Meatus 315
(3) Cncumsciibed Inflammation of
the Kxtci nal Auditoi y Meatus 3 1 5
(4) Sweat Rashes 315
(5) Callosities -
(a) Onscttcr*' Hands 315
(o) Yard-Stick Callosities 315
(c) Pick-Shaft Callosities .110
B Ckeimccd Caitsei Divnum —
(1) Creosote Rash 316
(2) Water Rash 316
(3) Eczema of the Upper and Lower
Extremities 316
fntrodiichon — The Dennatitis Traumatica
ot Venenata iv Coal-miners form a very interest-
ing study to every colliery suigcou The dith-
culties attendant on such an investigation are,
however, numerous The separation of the
influence of general hygienic surroundings, of
poverty, of heredity, and of treatment in a
more or less migratory class of workers from
the direct influences exerted by the different
occupations is clearly a foimiduble difficulty
All pit-workers do not suffer alike Some have
skins far more liable to lesions than others, so
that an exciting cause in one case may have no
influence in auothei Again, those pitmen \\ho
aic not unduly susceptible to either physical or
chemical agents may bho\\ no deimatitis on the
hist application of an external niitant, but may
do so if en en instances expose them to its in-
fluence frequently
On the other hand, the history aids one gteatly
in amvmg at a logical conclusion us to whcthci
the disease is the icsult of occupation 01 not
The lesions aic often quite local in then distil-
bution and then etiology easily accounted tot
Not only is this the case, but when the afiection
is seen only in those employed in mining, and
when theie is a lopotitinn of at ticks undei
sirmlai cncumstaiices, coupled with ieco\eiy
when the cause is jemoved, one has no dith< ulty
in stating that the disease is one due to occupa-
tion The conclusion which one is duven to is
that of the inflammations of the skin occurimg
in mineis, and bi ought on by external nntants,
some aic due to physical and some to chemical
causes
A Phi/Mtal Cuusei DUHSWH —
(1) Intei hujo. — This affection usually makes
a sudden appeaiance between two opposed sm-
taces of skin Its favourite situations aie the
axilhe, lowoi half oi extcnsoi surface of light
aim and inside ot lowei third or lo\vcr fourth oi
light thigh in light-handed he\\crs, the lelt aim
and leit thigh in lelt - handed hewers, groins,
sci oto-femoral clefts, seiotum, perineum, natal
cleft, glans penis, and piepuce The sensations
puxluced aiu those oi heat and piuntus
The lustoiy usually given is th.it the skin on
the opposing sin faces became chafed and now
feels hot and soie The first appeaiance w
simply a middled surface, which, howevei, soon
becomes taw us well as redder On further
nutation a fluid exudation co\cis the suitace,
and the result is a scalding or maceration of the
affected area or areas of skin accompanied by
the production of an offensive odour The con-
dition may end in an cc/cma
The etiology of this affection comprises a
number of factors Heat, moisture, contact,
piessuic, movement, and fuction all play their
pait In addition, coal dust and coal-particles
accumulate m the situations above mentioned,
and by irritating the skin, especially \vhen per-
spiration is practically dropping off the skin,
cause an mtertngo Another factor is the want
of cleanliness, especially in the region of the
genitals In their daily ablutions some mmeis
omit the latter region or only cleanse it partially.
Again, the right-handed hewer who works with
the back of his right elbow and the lower half
DERMATITIS TRAUMATICA ET YEN EN ATA IN COAL-MINERS
315
of the extensor surface of his right ana againbt
the inner surface of the lowei third or lower
fourth of the right thigh produces an mtcrtngo
ot the paits 111 contact In no case, howcvci,
have I been a malignant condition tesult such
OH one gets in sweeps
The ticatmcnt which h«is been found to be
most sei vie cable oonsists in warm local boric
acid baths followed by the application of car-
bolic oil (1 in 30), combined with rest of the
affected parts Strips of dry bone lint should
be placed in the discard clefts after oath appli-
cation of carbolic oil, 01 they inaj be soaki d in
the oil pievious to their being applied (Kule
oi xmc, staich, bismuth, calamme, fuller's
eaith, and othci po \\deis of the same natuio, or
combinations of these so-railed hannlesspowd' is,
do tar more haiin than gocxl, and gtcatly encour-
age .1 relapse th tough then tendency to cake
("2) Eczenw of the Erteiiud Aiulitoii/ Mt'utuv
— Eczema in this legion IB usually of the acute
\esif ulai typo, and is to ho met with in all
degtccs of seventy The chief cause in coal-
inmcis is the nutation pioduced by the ptcsoiue
oi coal-dust and 5- tone-pai tides which gam access
to tho external auditoiy nieatus while the hewer
IH working, as he often has to do, with his hoad
abducted A tight-handed hewer would thus
ILIAC the loft car atteetcd, a left-handed hcvrei
the light eai The sharp and angular paiticlcs
of stone aie moio <ipt to caime nutation than
the particles of toal If the common is abund-
ant, tho particles become entangled in it, and
the two ultimately form a plus.; of impacted
cerumen When temOAod, they aio seen to be
usually tubulai, and they Aaiy in length ftoni
\ to ;{ of an mt h Such a r ouditioii causes an
impairment of hoaimg, .ind gnes encouragement
from its rocmrcnce to an attack of ec/ema In
Home of the occupations in tho pits the dangci
to life is increased by an auditoiy appaiatus
in bail working older, and hence pitmen soon
consult a medical man if theic be any sign of
deafness Should tho eczema cause a nairowmg
or toituosity of the canal tlmmghout its whole
extent, it may necessitate the pitman's changing
his occupation
Painting tho affected legion with f rial's
balsam seems to fail in cut ing this ttoublesome
affection To soften the plug thick castor oil
should be dropped into the ear nightly fot
three nights in succession On tho fourth night
the eat -channel should be syringed out with
waim, weak bicatbonatc of soda solution, and the
plug extracted by a Volkmaun's spoon 01 small
foiccps if need be The ear is then plugged
with nartow stnps of lint which have been
previously saturated in molted mild antiseptic
ointment Tho meatus soon icturns to a noimal
condition If eczema of the ear has already
developed, syringing with warm, weak soda
solution eases tho pain, and this, when pci-
formcd every second or third night, may in
itself be sufficient to cure the eczema If not,
the solution should be mopped up after synng-
ing, and boric acid in fine powdet blown into the
eat Salicylatc of soda solution (1 in 50) is
useful in allaying the pain also
(3) CMiuntifCrtbeff Inflammation, of t/if EJL-
lei n<tl Auditoiy Meatus — I\M affection uMially
shows itself in the foim uf small boils It is
accompanied b} a good deal of pain, the patient
is usually "run down1' in condition, and hence
icqmres systemic as well .is local tieatinent
Tho lattei ron.si.sts in inewion of boils and
syungmg with waim, weak boric solution
Strips of lint soaked in catholic oil (I in 40) are
Aorj soothing as well as healing
(4) tintfit fire-he* — These a*v common, and
<uo usually ot an ei \ thcmatous typo, often
seal Utimhii m A stiong dose ot calomel usually
has tho best effect
(3) CallMitta — (a) Otisettei s' Hands — This
is a laro and pecuhat condition resembling
J hipuj tiou's contiaction Coal is removed from
the plate wheio it is hewn, to the pit-mouth in
tubs Souths, c, tiled onsettcis, have to push
and pull these tubs, which ate simply small
lailway waggons capable of holding, say, six
hundiedw eights of coal They do so by grasp-
the upper tim ot the tub with the hands m a
position of somifloxion The mo\ emcnts of the
hands cause oft-repeated ptessure on the palms
and on the flexor surfaces of tho digits, with the
icsult that the skin gets thickened and callosities
form on the ateas exposed to ptessuic No
pain i,s CApeiicnccd, but the reti action of the
tascial sttuctuics is slowly piogtessnc, and
results in a \aijing degree of flexion of the
digits The middle hngei sutlers most, and
hence diffcis ftom Dupuytien's conttaction, in
which the middle finget is not so much flexed
as the two innei ones The condition is often
bilateral Hot baths nightly, followed by
eneigctic inunction with fatty sul>stances, or the
application of stimulating liniments, entirely
fail to make any lasting nnpiession except at a
\oiy caily stage Subcutaneous division of tho
contracted strut tin es seems to be the only real
lomcdy
(f>) Yaid-htuk Callosities — Ofheials carry
^ard- sticks occasionally whilst tiavcrsing the
low passages of the pit, and callosities some-
times icsult ftom the grasp taken Such a con-
dition might piovc useful in the identification of
officials found dead In one instance brought
to my notice by Dr Trottet of JJcdhngton the
oftuial obtained suppott ftom his yard -stick
while walking in a stooping position by grasp-
ing his wand about the junction of its upper
and middle thirds in such a manner that two
callosities \vcie pioduced By fully flexing tho
little hngci of tho right hand on the palm, and
stick was grasped in such a way that a callosity
de\ eloped on the extensor aspect of tho proximal
316
DERMATITIS TRAUMATIOA ET VENENATA IN COAL-MINERS
phalanx of the little finger, and another on
the flexor and inner surfaces of the base of the
thumb.
(e) Pick -Shaft Callotities -—Every hewer
shows a number of callosities on both hands pro-
duced by the constant grasping of the pick-shaft
whilst working These vary m position accord-
ing as the hewer is left- or right-handed, but
only to a slight degree, aw the miner may ha\e
to use his left hand most the one day and the
nght the next
B Chemical Causes Division —
(1) Creosote Rash— Props of wood ure used
to support the roof of the mine, and the piocess
of placing those m their positions is called
" timbering " The prop* themselves ure soaked
m preservative solution or volutions to protect
them from f ungi and moisture in the pit I am
unable to give the composition of any of the
prcseiving fluids — the foimnl.e seem to be
trade secrets , but. since the preparations smell
vigorously of cioosote, the iash is here termed
the Creosote Hash Mmcin aic afiaid of hand-
ling too many pickled pi ops, ' which die Mack-
stained and used for the dampest juits oi the
pit One meets with the cieosote iash usually
m adolescents who have been engaged in hand-
ling creosotcd logs for several days in stic< ession
The Hites of predilection are the hand* and
wrists, face and neck The iash makes its
appearance in the form of a laigo mimbor oi
small papules, about the bizo of a pin's Imul, but
gradually passes from this erythematous condi-
tion through a vesicular stage into a pustular
one The pustules tend to buist, and the con-
dition assumes the appearance of a pustulai
eczema The dark -brown staining mateiial
contained m the piesurvmg fluid may assist in
the pxoduction of the creosote iash As a
complication of this affection I may mention
conjunctivitis, both simple and pmuleut This
m produced by the pitman rubbing his eyes
with his unwashed hands \vlnle at work 01
before he takes a Kith The tioatmeiit which
yields the best results consists in bathing the
affected parts with a solution of sal icy late of
soda (1 in 50) for fifteen minutes every morning,
and following this up with a liberal application
of boric acid omtment — the whole to be repeated
at bedtime This is assisted by a general tonic
or sahcylate of soda internally, the affected parts
being kept at lent as much as possible
Vfho general symptoms accompanying the rash
are) briefly as follows — ShivoiH, loss of appetite,
headache, backache, malaise, and sickness
Papular zash appeals when temperature is about
101° F Temperature falls to about 99 5° F
whVi vesicular rash exhibits it&elf, and rises to
102$" F or higher when the vesicles become
pustular It then gradually fulls to the extent
of oneVlpgiec daily until it reaches normal
The ski^ shows no sign of pitting, and the
vesicles ar^ not umbihcated
(2) Water-Rath. — This eruption may be pres-
ent on any part of the body, although it favours
the hands, forearms and arms, face and neck,
and the feet and legs It occurs m those who
do not handle props as well as in those who do,
and simulates the creosote rash in many of its
symptoms It is apparently caused by the
water m the pit, either by its dripping on the
pitman whilst at woik, 01 by his getting wet
with water lying on the floor of the mine The
whole course of the disease, the rash especially,
simulates smallpox The rash is first pupulai,
then xcsiculai, and finally piibtulai Some of
the pustules show distinct umbihcation The
systemic distmbante is also similai to that of
an infectious disease Pit->\atei m percolating
into the pit dissolves many irritating materials
lu addition theie is, cornp.it atively speaking, a
good deal of sulphuietted hydiogen and siilphui
dioxide m the an of mines, and these when dis-
solved m the water may act us factors of causa-
tion, just as m the case of Delhi boils The
treatment consists m administeimg a good
diaphoretic and diuretic mixtui e i egularly The
diet should bo light and non-stimulating, and
the patient should be confined to bed Tins
iobh seems to be a formmnei of the «'• A ma of
the feet and legs \\lnch one occasionally meets
with m old mineis
(3) Kczema of tfte Uppn an<l Lowei Ki-
ttemitie* — Thih is an aggiavating condition to
cuie When fully developed it attacks both
hands and wrists as well as the doisum of each
foot, and it may be that even the legs arc in-
cluded The skin peels off in laige flakes fiom
the palms of the hands, and fissures usually
extending down to the ti uc skin make their un-
welcome appearance lioth hands suffer equally
The condition is axeiy sonousonc to the uiinei,
causing him much pain and anxiety thiough
loss ot woi king-time Undoubtedly one ian
remove the disease by remowng the cause in
time, but pitmen show no delight m changing
their occupation unless really compelled to do
so fioui the seventy of the skin lesion One
must therefoie adopt the pnnuple of trying to
avoid depiivmg the skin of its natural lubricant,
.ind to supply a substitute where the lubncating
material is deficient The handling of props
ought to be discontinued therefore, and caihohc
oil (I in 40) should be energetically rubbed in
night and morning Lead and opium lotion
gives relief, as also an ointment consisting of am-
momatod mercury and oxide oi /me Despite
all kinds of treatment, however, the disease may
remain perfectly incurable
DermatObla.— A bot-fly, found in Cen-
tral America, which deposits its oggs in the skin
and causes boil-like swellings (cutaneous myianti>)
DermatOl.— Subgallate of bismuth, a
dusting powder and an antiseptic ; used also in
diarrhoea
DERMATOLOGY
317
Dermatology. — The department of
medicine dealing with the diseases of the skin.
DermatOlySiS.— Abnormal extensibility
of the skin due to an alteration in its contractile
faculty , also extensibility with a certain degree
of hypertiophy affecting various elements of the
skin and subcutaneous tissues, leading to the
localised production of hanging or loose folds of
skin, cuti& lava , cutis pcndula , "elastic-^""""*
men " Nee PREGNANCY, INTRA-UTERINL x,, ,_ .
(Dtseates of tlie Nubcntaneow Tissue)
DermatomyCOSlS.— A cutaneous af-
fection due to the giowth of a vegetable parasite
such as dcrmatomycosis furfur i,eu or tinea
vcrsicoloi (due to growth of nucioywon fin fur)
Nee SKIN, I'ARAHIIEH (Tinea)
DermatomyOSitiS.— An inflammatory
disease of the muscles associated Mith u'dem.i
and erythema , polymyositis Nee MUSCLES,
1 )ISE ASES ( In flam mi ton ?/)
general term applied
to all skin disease •., and seiving as the ba^is of
the nomenclature and elassihejition of dermato-
logy , angioneurotic dcimatoscs, h.emoirhagic
deinmtoses, and neuiotic dcrmatoses, etc , have
been described /fte-Skix, DISEASES, PAIUHIIES,
DRUG ERUPTION h , etc
DermatOSpasm US.— Cut i^ ausenna
Nee CUTIH
DermoKraphia or Dermo-
graptliSm.— The condition of the skin in
which the stioko of the fingci-nail 01 of the
point of a pencil \vill laise a Imcai \\heal, mak-
ing it possible to \vntc a \vord or Uo on the
patient's back or chest Nee URTICARIA ( Vant tie^
Uitnnna Factttta) , H\SIEUIA (Di \onh 11 of
C n dilation and Tiop/uc Dtboidos)
Dermoid Cysts and Tumours.
See BRAIN, SUKUERY OP (Cephalocele, DiaanoM*) ,
CON JUNOJ1VA, DihKAHW OF (Congenital Anomalies,
Deft moid Turnout*), EMUUYOMATA , K^ELIDS,
AFPEOTIOVS OP (Congenital Defect*, Dernwid
Cysts), FALLOPIAN TUBES (Turnout*, Pumati/
Detnund), LACHIMAL APPARATUS, DisEASEb OP
(Dixtweiof Laainial Nat and Natal Duit, Dti-
mwd Tittnou) s) , LABOUR, PRECirirATE AND
PROIX>NOKD (Faults tn the Moft Pa^ayes, Ovarian
J)e»noid), MEDIASTINUM (Tumours, Deimmd
Cybtv) , MOUTH, DISEVSBS OF (Dueaw of Flow
of Mouth, Dernund Cytts) , ORHIT, DISEASED OP
(Tumours, Cythc, Dnnunds), O\ ARIES, DISEASES
OF (Turnouts, Det mmd Cysts) , OVARIES, DISEASES
OP (Ptimaiy Dennotd of Pelvu. Connective
Tinnue) , PALATE (Tumours, Dtrmoul'*) , PERI-
TONEUM, TUMOURS OP (Dernwids) , Scumuv AND
TESTICLE, ])isEAhES OP (Tumocr* of Nctotum,
tfeffuestration Deimoids) , TONGUE (Turnouts,
Cysts, Dermrnd) , TUMOURS (Dei moid* and Teia-
tomata)
DermoideCtomy.— Exunion of a der-
moid cyst or tumour
DeriTIOl.— Chrysophaiiate of bismuth
DermotylOSlS. — Hardening or indura-
tion of the skin
Derodidymus or Derodymus.—
A monstrohi y (from (>t ^c/n/, neck, and 8un»/xos,
'oublc) wiMi t\\o heads and a single trunk
j (\vith two v rt l>ial columns), and two arms and
I two logs, .uic7 ' f'lh.ips the rudiment of a third ,
d.cophalus d f • 01 tTipus
. — A parasitic monstrosity
(ir • i >,, iock, and /«Aos, 1 nb) in which
a limb sji- ^s from the legion of the neck , a
traeljJo ]> rasite 01 aiicheno-melus
Desalination. -The removal of saline
substtuucs from Uu» blond (e </ in ciioleia).
Desault'S Splint.— An app,iratus (long
outei and inner splmtn, and an anterior splint)
used 111 fractures of the thigh, totalled after
the Ficnch surgeon, Desault (174-1-1795)
Descemet's Membrane. — The
posterior elastic lamina of the cornea , inflam-
mation affecting it is called Dcscemetitis ,
Dcsccmet %\as a Ficnch physician (1732-1810)
Nee CORVK\ (hit toil action) , IRIS AND CILIARY
BODY (Anatomy)
DeSCensUS.— Descent, fy of the testicles
in foetal life , pi elapse, e g of the uteius Nee
SOROTUM AND TFSTICLE, DISEASES or (Develop-
ment, Descent oj Tetttde) , PELMS, PERINEUM AND
PI-LMC FLOOR (Ptolapvu* Uteri).
Desiccation.— The action of drying up
or dcpiiMiig of moistme A deticcatot is an
apparatus for the diymg of fruit, milk, etc ,
powcifnl dchydiatmg agents are concentrated
sulphunc acid 01 fused calcium chloiide
Desma- or Desmo-.— In compound
\vords drima- 01 de*mo- (from Ur Secr/xfj? or
8&rfJM, a ligament 01 band) means relating to a
band, bandage, or ligament, 01 to any connecting
stiuctuie Thus detnmtyte is a t onnectivc-tissue
coll , deimalt/ia signifies pain in a ligament ,
dcimtct<t\n is sti etching of a ligament, dct>mo-
fjinphy 01 dcwolofjy means the description of the
ligaments , det>moid tumour is a hbioid , desnionta,
w a tiimoui of the connective - tissue type ,
rfejwiosts is a dibc.use of the connective tissue,
especially of that of the skin , and desmuraia is
the surgical treatment of discuses or mjuiies by
bandages
inicro-oigamsms, in contrast to the spheero-
bacteria or cocci (round organisms), in Cohn's
classification
318
DESQUAMATION
— The separation 01
exfoliation of the epidermis, cither in mem-
branous pieces (dev/uamatio nwmbiaruicea) or
m ^mall particles (desquamatio furfwacea), or
as a complete portion or sheath (desyuamatto
,Wtgwo*a) /•>'<•<• MEASLES (tiymptom*, Et uption) ,
NEW-BORN INFANT (DerutttMti Jfjcfoliativa) ,
RUBELLA, ROSERASII (Symptontatoloyi/, Devquama-
tion) , SCARLET FEVER (fymptomatoloyy, De-
sqwvnation) , SMALLPOX (tiyjuptom^ Et uption) ,
TYPHOID KEVER (Complication* and tieynehr,
Cutaneous tiyt>tem)
Desquamative Nephritis.— Renal
influinmatioii m winch the epithelium of the
tubules of the kidneys is cxtouHively shed
DestrUCtOr.— An apparatus foi the
effluent and cleanly disposal of i of use by means
of heat , eithei the slow combustion furnace
(««/ Flyer's) or the high tcmpci.itme 01 forced
draught furnace (c f/ Horsfall's) may be used ,
there may be also a fume ciemator for consum-
ing tho fumes , from the resulting elmkei con-
crete may be obtained foi making roads, moitnr,
etc
Detachment of Placenta. .v«
LABOUR, STAGES AND DURATION (Third Staffi,
Phenomena)
Detachment of Retina. ttr
RETINA A\D OP no NJCIIVB (Retina, Detachment)
DetentlO.— Catalepsy
Determents. — Cleansing substances,
especially such as remo\o dnt, dischaige, [iind
desquamated cpideiimc sealcs fiorn the skin 01
from foul ulcers by their exteinal use , examples
arc found m soap and warm water, alcohol,
vinegar, charcoal, pumice-stone, and band
Determination.— The flow of the blood
(and of other bodily fluids) to a special part,
leading to congestion of that part, actnc
hypertemia
Determination of Sex.— The aiti-
ficial fixing of the sex of the offspring before
birth is still an unsolved problem , it docs not
feeem that it can be done by altering the food
given to the female patent during pregnancy ,
the general tendency of modern investigations
is to show that the sex is detei mined at an
eailier date in antenatal life than was supposed,
either at the moment uhen the spermatozoon
penetrates the ovum or in tho ovum itself before
impregnation, pel haps at the moment of matura-
tion , the medical man cannot yet fict as " tho
arbiter of the sex of the infants yet unboin "
DetrusOr. — Literally a thrustcr-out or
propeller (fiom Latin detrudo, I thrust away) ,
IB the name given to the muscular coat of the
bladder which by its contraction expels the
uiino (detruwt unnut)
Deutero*. — In compound woida deutero-
(fiom Greek &UTC/OOS, second) signifies secondary.
Deutero - albumose. >sv« URINE,
PATHOLOGICAL CHANC.KS i\ (Detection of Al-
bumosesin Utine).
Deuteropathic Insanity. — in-
sanity caused by morbid states of other oigans
than the biam , secondary insanity.
Deutero- proteoses.— Proteids with
a loss complex molecule than the albumins and
globulins have, and more nearly allied to the*
peptones than to the original pioteids (The
jji'oto-jttoteoses, on the othei hand, are moie
nearly allied to the onginal pioteids than to the
peptones ) tiee PHYSIOL<)(»\, PROFOPLASM (Clafu,-
hctttivn, of t/te Prottnh) , PmsioLom, FOOD AM*
DIGESTION (Stomach, Dn/n>tinn, Pioteolytts
Peuod) , Pin SIOLOCJY, FOOD AND DIGESTION
(fntfsttiifil Dir/ertion, Pnnncatu).
Deutoplasm or Deuteroplasm.
— The food yolk of the o\ urn, * e oi the mero-
blastic ovum , the deutoplasm of the hen's egg
consists of white and yellow yolk , the nutntivc
yolk m coutraflistinctioii to the protoplasm 01
toimati\c yolk
Development. — The series of changes
by which an appaicntly simple structuie (e y
the ovum) becomes a highly complex oigamsm
(ff/ the embryo and fojtus) , also the giadual
elaboration of stiuctuie and function believed
to occin in and to .lecount ioi the evolution of
i.icesof animals and plants , "creation belongs
to eternity and development to time " (Stew ait
and Tait) «SVr (/HILDREN, DEVKLOPMFVT OP ,
EMHKYOLOG\ , F(Eiu.s AND ONUM, DJIVKLOPMEI^T
or, (JENKnArroN, FBMAMI, OKOANS oi (Airested
Development*), HKXRT, PirvsjoUJdY i)V\(Emlnyo-
low) , PALAIK (Confjetiital Maltot muttons of
Mouth, Development), PHYSIOLOGY, REPRODUCJ-
TION (Development) , PRKONANC^, JMnsioLoav ,
PKKGNANCY, MULTIPLB (Twins), SnioTUM AND
TESTICLE (Abnormal itif>) , SMN, ANATOMY AND
PHYSIOLOGY (Skin, Naih) , TEETIJ (Dewlfywu nt) ,
TERAJOLOG\ , UIFRU.S, MALIORMAIIONS OF (De-
of Cttuto-UiiMuy Ox
Developmental Idiocy.— Congeni-
tal cases of mental deficiency in which the signs
of the morbid state are late in appearing *SVr
MENIAL DEFICIENCY (Developmental)
Developmental Insanities. —
Uiidfi this name have been grouped the de-
liriums and night terrors of thildien and the
Aarious insanities of puberty and adolescence
tiee ADOLESCENT INSANITY , NIGHT TICKKORS , etc
Developmental Method. — The
spinal cord at birth has tracts (ingoing) which
contain mednllated ncive fibres, \vhile others
DEVELOPMENTAL METHOD
319
(outgoing) do not, by this fact the various
tracts ot the cord can be demonstrated See
PHYHIOLOGY, NERVOUS SYSTEM (tipnial Conlt
, Conducting Path*).
Deviation. — A departuic fioni the nor-
mal bUte , deflexion or vanation, ey divcigcncc
ot one 01 both optic axes, fiom the noimal posi-
tion >SW OCULAR MUNCLKh, AF1LC11ONS (Pata-
Jyw, Etioloi/y) , NOSE, Disc \SKS OP NASAL
ORIFIOLS AND SEPIUM (Deviation of the He^tum
-Yaw)
Devonshire Colic.— Cidci (from its
acidity) easily afiects lead with which it cornea.
in contact, so lead-poisoning may be pioduccd
by dunking cider This may account foi the
frequency of plumbism in DcAonshnv »S'»<
Toxirouxii (hutants, Lead)
DevOto'S Method.— The use of phos-
pho-tungstic acid 01 tannin for the piecipitation ot
dlbumuses in mine ,SVe URINL, PAiiioLooirAi
CHANGES l\ (Detection of Albunw^et)
Dew. tire MEILOHOLCMA (Dew and Hoai
fao*C)
DexiOCardla.— Tiansposition (congeni-
tal) of the heart to the light side of the thorax,
localised 01 partial heterotaxy, tilso \\nttcn
devtiocaidia *SW HKAKI, CONGENITAL MALMW-
MAIIONS (Df/tlOt'lldltl)
Dextrin. — A caibohydiate (CtoH ,„<),),
called British gum, closely allied to nmlin,
obtained from starch by the action of dilute
acids, of diastase, and of animal feiments , it is
<t pol^sacchand, got by the polymei isation of
glucose or dextrose (C1,,!!] /),,), the hist dextnns
formed by the action of salua on starch gi\e a
blown coloui \\ith iodine and aie called ttythto-
dejrti tits, the next give no colour (a(/noodt'Jiti im)
tiee PmsioLOGY, FOOD AND DIGLVTIOX (Food,
Cajbohydt ate.*, PolysaccfMrtdn)
Dextrose. — (ilucose, gr.ipe sugar, 01
blood sugai, the aldehyde of mannite, <i simple
carbohydrate (C^H,/),,), or mouosacthaiid , it is
so called because it is dextio-iotatoiy, i e rotates
the plane of polanscd light to the light, and
thus ditleis from l<cvulose, \\hich it otherwise
lescmbles , it is one of the aldehyde sugais 01
af doses See CLYCOSUHTA , PH\HIOU>UY, ,FooD
AND DIGESTION (Cat bohydratev)
Dhoble Itch. «SVe SKIN DISEASES* OF
TUB TROPICS (Vet/< table 1'anmte*)
Diabetes. See ADRLNAL GLANDS, Anui-
HON'S DISEASE (Diagnosis, Jiton-ed Diabetes) ,
AI>COHOL (Indication*, Diabetes), ALOPIECIA (Etw-
loffy, Diabetes) , lioius AND CARJIUXCLB (Etiology),
BRAIN, AFFECTIONS OF BLOOD- VESSELS (Cerebral
Hwmonhaye, Diagtww from Diaftcte*) , BRAIN,
SURGERY OF (Com^iression of the Bram, Diaynosti
fiom Diabetic Cotna) , BREATH , BRONCHI, BROX-
cuniH (Etudof/y, Prediywnnrj Causes), CATARACT
(Idtojiathic, Causes) , CLIMAIK, ACCLIMATISATION
(Diabetei), COLON, DISEASES OF (Membranous
Colitis, tiecondaiy) , COLOUR VISION (Acr/uued,
Cautev) , DlAliKl'ES iKBll'IUVh, DlAHEPES AlFI-
LITU.S, KAR, MIDDLE EAR, CHRONIC SUPPURATION
(£V*ttSfs) , GAM.Hh.NE (Diabetic), INSANITY, K'HO-
IOGY OF (GVeuws, Autotojcu.) INSANITY, PATHO-
iofi\ OF (Pat/tofjeneti*, Diabetic Insanity) ,
INSANITY, NATURE AND S\MITOMH (Etioloyical
I'mtetie*), JN\AIID FEEDING (Cookeiy in Dia-
bttet) , LUNGS, (IANGRKNL oi- (Cause*) , JJUNGS,
V.«s< LI AH DISORDER^ (Pu/nifmaiy E/nboliwi, Fat
Entbolt), MIIK (Tlurtqimtic U*e<*) , MiutPillNd-
^f\^lA AND ALLIRD Dutu HAI>ITS (Paraldehyde
Habit, Dtaf/jiosii> , MusciES, DISEASES OF (Poly-
tnyoMtii, KtirJfji/v), N\ILS, AFFECTIONS OF THE
(fn (it-nfittl DMOMI) 9 SERVES, PERIPHERAL
(AJrwi.fis C'iu\e<t) , NERM-S, MULTIPIE PERI-
PHFK\L\tUKlUs(£l//0/«////)> NlKNES, \KURALGIA
(KftoliM/y) t OCULAR MLSCIES, ApnvnuNS OF
(Pfltatyui, Etioloift/) , PAN( RRAh, PllYSIOLOGY
01 (Relation of Dtabetrv Mellitttv to Lewon of
Pannea*), ()\ ARIES, DisE\sEh or (Ovariotomy in
Diabetic tiubject*) , OX\G*N, USES 01 , PBMS,
SURGICAL Ari-ECi IONS or (Jiatanttn), PHARYNX,
Cimovic PHARYNGITIS (Ettof<M/y) , PinsioLotn,
IM'W{NAL StcREriONs (tfujitaitna? Jlodtes, Pan-
trcas) , PREGNANT, AFFECTIONS AND (JowrLiCA-
TIONS (Digestive, Diabetes), PRUKULS (Etwfoyy),
PULRPERIUM, PmsiomGY (Eiuetory tfyt>tent,
(rlytwuHti) , RbFR.\niON (h ri/per •metrojna) .
KFTIVA AND OPTIC NKRXK (Rtttnal llirmorrlvaye*,
f/rt?/sei , Diabctn JKetinttis) , SKIN, PIGMENTARY
A i rETTii )NS oi (Cla ss/ feat ton, Tojcwm H ) , TEEI H
(Dental Catiev, Cauvk), TiiFRAPRLiK s, HEALTH
HESORIS (Waim Climate for Diabetic*) , UNCON-
sr lousNhss (Aufo-intottcationt) , ITHINF, PAPHO-
KK.ICAL (CHANGES IN (AllWlOHia, P/tOSJi/Ulte*,
tiut/at *, and A^ttone in Ui me), X-ltA\s(/?/a/>f<es),
XANIHOMA (Xanthmna Diabettcot urn)
Diabetes Insipidus.
KTIIHXX.Y 319
S\MPIX)MS AND Dl\GM)SlS 320
PA rani i M.I 320
TllFAIMKM 321
is <i disease chaiactei isod
by a piolongod moibid increase m the secretion
ot a urine fiee fiom sugar
KTIOLOM — Diabetes msipidus is a compara-
tively rate condition Dining a pcnod of six
ycais t\\onty cases ^ere undci tic\itnicnt in the
wards of the Iloyal Infirm.uy, Edinburgh Ac-
cording to the statistics of Roberts, Strauss, and
Vein dei Heijden, the disc.iae is most common
during adolescence, early manhood, and middle
life Sex seems to play «i not unimportant part
as a predisposing factor, males being twice as
frequently affected as females. A marked
family predisposition may exist, the disease
320
DIABETES INSIPIDUS
running through neuropathic families or alter-
nating with other nervous or mental troubles
Thus Griesmger in 0110 instance found that
seven blood relations of the patient \vere epi-
leptic, m two instances the patient himself was
epileptic, in one instance both the patient and
his friends were epileptic Gee notes A family
where in four generations of 23 patients 11
Buffered from diabetes insipidus , Oisi, a family
of 9, 6 of whom weie affected , and Weil, a family
of 21, '20 of uhom developed the complaint
The causal relationship between syphilis and
diabetes insipid t is is not yet quite cleai In
most cases the condition must be ascnbed to
cerebral gurnuia or end ar tent is, but a number
remain where the exact condition cannot be
substantiated In brain diseases tubeiculobis
must not be foi gotten in diabetes insipidus m
childhood, and two cases have been described
where chrome hydrocephalus existed
The acute infectious diseases, gout, tiauma of
the head 01 abdomen, mental shock and woriy,
exposure to cold, a tout of drunkenness, neglect
and improper feeding, with consequent mal-
nutrition m children, may all ha\e a causal
relationship to the disease
SYMPTOMS — Two prominent and char at teiistic
symptoms are piesent in the disease — an increase
in the amount of urine excreted and a marked
and distressing thirst The onset of the disease
may bo insidious or sudden , there is complaint
of increased fiequency ot micturition and in-
crease in the amount of urine passed, distressing
dui ing the day, and preventing proper sleep
during the night The amount of urine is enor-
mously increased, as much as fifteen to twenty
pints being passed in twenty- tour hours Kxcept
in the later stages of the disease the amount
of urine excreted exceeds considerably the
amount of fluid ingested, the surplus being
made up from the food and the tissues of the
body. When, howcvei, a ccitain stage of the
disease is reached the tissues become dehydrated,
and this disproportion is lost. The urine is pale
in colour with a yellowish or greenish tinge
The reaction is faintly acid or neutral The
specific gravity is always low — 1002 to 1005
Glucose is absent, but mosite or muscle sugar
is frequently present, but its presence is not
characteristic, as it may be found in chronic
interstitial nephritis, and even in health after
an excessive amount of water has been drunk
As a rule albumin is absent, except in the later
stages of the disease, when it may be present as
the result of the general dyscrasia and dis-
organisation of the kidneys The urine on
standing may become turbid from the deposit
of epithelial cells , crystals of oxalate of lime
may be present, and phosphates may form from
ammomacal decomposition The peicentage of
total solids is small, but the total daily excretion
of nitrogen may be slightly increased The
chlorides and phosphates are increased. The
thirst is excessive and distressing. Enormous
amounts of fluids can be swallowed by the suf-
ferer Trousseau recounts the case of a young
man who daily drank forty litres of fluid and
passed forty-three litres of urine Under treat-
ment, when unable to get water the thnst be-
came so intolerable that ho drank the contents
of the chamber -pot
The mouth, touguo, and fauces are dry and
paichcd The appetite may be unaffected, but
it IN usually increased, and in the caily stages
of the disease may be voracious Digestion in
the earlier stages of the disease is normally per-
formed The bowels may be constipated The
tcmpoiature is as a rule subnormal The skin
is diy and harsh The ncivous system is dis-
turbed When tin1 condition is due to a gross
ccrebial lesion paralysis of cranial neivcs with
hcmianopsia may be piesent The sensory func-
tions are usually abnormal, thus pains in the
back and legs and a tendency to headache,
tingling and itching ot the skin may be present
Amblyopia is common w ithout any discoverable
lesion The mental functions ate below par,
the patient being nn table and depressed In-
somnia is distressing The sexual povteis uic
enfeebled
The pi ogress of the disease is vatiable At
times the condition is so slight as to bo regarded
more as an annoyance than as a disease In
more sevcio cases piogicssive deterioration in
nutrition sets m, the muscles waste, the appetite
diminishes, digestion fails, and attacks of
diarrhoea supervene The patient becomes
exhausted, diowsy, and giadually comatose, un-
less carried oft by an mtercurient attack of
hypostatic pneumonia
DIAGNOSIS is not as a rule difficult The
increased excretion of water in diabetes melhtus,
intermittent hydronephiosis, chronic inter strtial
nephritis, and in hysteria, may occasionally
simulate that symptom in diabetes insipidus,
but these conditions are otherwise readily differ-
entiated
The yytoqnw* in diabetes insipidus is vciy
variable Each one must bo judged upon its
own merits At times the health does not suffer
appreciably Cure may sometimes follow an m-
tercurrent affection such as measles Idiopathic
cases may last for many years, and terminate in
a gradual loss of nutrition or in an rntercurrcnt
attack of pneumonia or with a slowly progressing
tuberculosis Once anorexia sets in the end is
not far distant. When a gross cerebral lesion
is present the diagnosis is bad When the
disease appears m childhood the general develop-
ment may be retarded and deficient
The pathology of diabetes insipidus consists
essentially of an error m the controlling power
of the vasomotor nerves of the kidney In
animals polynna has Ixjen shown to follow
stimulation of the floor of the fourth ventricle
or cerebellum. >In man the stimulation may
DIABETES INSIPTDUS
321
result from pcriplicr.il mitation , an abscess of
the external auditory meatus has been known
to produce marked polyuna, which subsided on
evacuation, to return when the free discharge
of pus was obstructed, to disappear again as
healing took place In animals section of the
great splanchnic nerve is iollowed by persistent
hypersecretion from the kidney on the same side
In man Schapiro has descnbed degeneration and
atrophy of the gaughonic cells of the semi-lunar
ganglia, and degeneiation and destruction of the
.IMS cylinders of the great bpLmchnic nerve in
diabetes insipid us Various lesions of the bram
may be present, as tumours, tubcicle, degenera-
tion and softening following aitcnal changes
Theie is no chaiactcnstic lesion in the kidneys,
though in long-standing cases secondaiy changes
may take ])lace as the lesult of the prolonged
excessive secretion of urine
TREATMENT — The tieatmcnt of diabetes m-
sipidus, founded as it ih upon an impcifcct
pathology, is not entirely satibf.ictory When a
definite dysciasia exists, such .is tubeiculosis or
syphilis, as a caus.il factor, tieatment must be
directed to its amelioration by suitable remedies
Apart from this, ti outwent by drugs has, foi
the most part, been dnectcd to influencing the
condition thiough the nervous system Valerian
\vas achocated by Tioushcau in enoirnous doses
of 10 {iims pei diem, piogiessively increasing
to 30 gims (Jiven thus it inevitably results in
uastnc disturbance Smallei doses of fjss to
z,j of the tinctuie tlnu*e daily, \vith camphoi
watei 01 spmts of chloiofoim to disguise tho
taste, prorliue <> decided, but unfortunately but
passing impioveinent, and tujy effort at me leased
dosage is lesented by the stomach Ergot has
a decided ainehoi.it ing influence, and may be
suitably pi CHciihed as ergotin in 2-gram doses
in pill with evtr.ut of belladonna, given eveiy
si\ hours, the eilects being \\atched lest eigotism
be produced Nitioglycennc, again, has pro-
duced decided benefit in a numbei of i.ises
Antipynn may piovo useful at night as a sedati\e,
and temporal ily diminishing the exciction of
ui me, and thus pei nutting sleep Salts of iron,
arsenic, zinc, strychnia, belladonna, mtiate of
silver, carbolic acid, and the biomides have all
been pi escribed with varying success Drugs,
m fact, may diminish the excessive scciction oi
urine for a time, and have a beneficial effect on
the gencial health, they do not cure the
disease Ergot, belladonna, and' nitroglycerine
are most to be recommended Electricity has
had a marvellous curative effect 111 some in-
stances It may bo applied to the medulla, tho
positive pole of tho galvanic current being
applied to the back of the neck by a large
electrode, tho negative pole, suitably insulated
to within a quarter of an inch of its extremity,
being passed along the floor of the nostril to
reach the spine The strength of the current
should be gradually increased from one to
VOL II
five milleumpeics, the duration of the applica-
tion from one to five minutes The negative
pole may be applied to the epigastnc region
instead of to the posterior wall of the naso-
pharynx
Diet and general hygienic measines are of
great moment in tho treatment of the disease
It is unnecessary and ct ilcl to needlessly restrict
the amount of fluid diunk, and only leads to
deterioration in the general health The daily
consumption of fluid should be ascei tamed, and
a giadual diminution advised till it is found
that the ui inary exciction is no longer influenced.
Thirst should bo alleviated with ice, acidulated
drinks, and the use of pilocarpme in small doses
Alcohol, aeiated waters, potash water, tea,
and ( otlee must be avoided on account of their
diuretic acid Food should be nutritious and
easily digested There is no objection to caibo-
hydrates, nor to pioteid lood within the limits
of the patient's powers of digestion If lestnc-
tion be placed upon the amount of food a care-
ful watch must be kept upon the patient's
weight It is better that food should be taken
ficquently m smallei quantity than in large
quantities at longer mterv als Little salt must
be taken in the food In the later stages, when
anoieua supervenes, the fluids diunk should be
nutritious, as milk, cocoa, whey, light bioth
(jeneial hygiene is of importance — gentle
exeieise, a bracing climate, and, as the tempera-
ture IK subnoiniiil, \\aim clothing are all im-
portant In the later stages caiefully legulated
massage is of gieat use (Jieat care should be
taken of the skin, w tin h becomes atrophic and
unhealthy Diyness maj be leheved by steam
01 vMum water baths Gentle f notion aids
nutiition Internment affections must bo
tieated on genet al pnnciples Constipation is
fiequently tioublosomc , di astic and niitant
puigatives must be avoided horn their liability
to set up seveic diarihuM Collection of faeces
ocein s in the lowei bowel, and is best treated
by large enemata, m.iHsage to the abdomen,
alom Jv giain in pill aitei meals, 01 fluid cxtiact
of eascai i sagiada in hall -drachm doses at
night
Diabetes Mellfitus.
DEFINITION J21
PHYSIOUJWf'AL OoNSIDEIiAlIONS . 322
ETIOIADGY AND KTIOLOGRAL KELATIONS 322
325
327
331
332
332
333
SYM1"IOMS, COWLICAUONS, AM) PATllO-
lot.iru, CHANGES IN CONNECTION WITH
THE VARIOUS S\STFMS .
PROUVOSIS
PAT.HOLOUICAT, YXAIOMY ^
PATHOGEN Esis
TREATMENT
DIABETES MKLLITUH is a disease m which grape-
sugar is persistently excreted in the urine The
21
322
DIABETES MELLITUS
term caimot be applied, however, to all cases in
which sugar is detected in the urine The cases
of temporal y glycosuna arc to be excluded , so
also are oases in which the sugai excreted is not
grape- sugai, as, for example, Uctosuna and
pentosuna The name diabetes nieliitus is
applied b> many writeis to all foims otpftmniifnt
glycosuiia Otheis use the teiin chionic gly-
cosuria foi tlu1 milder foiuis of the disease, in
which griipe-sugiir is present in the mine, but
othei symptoms slight 01 absent, andicsenc the
temi diabetes mellitus for the more scvoie foims
PlllSlOLOGlCAL CONSI DERATIONS Tilt) Caibo-
hydiatcs denved fiom the products of digestion
au" cornered by the poit.il vein to the Inei
This organ contains a <aiboh\diate, glycogen,
which is yioatoNt in quantity when a caibo-
hydi.itc diet is £ji\eu Wh«it the exact function
of the Inei may be, whether it is constant!}
paying out a small quantity of sugar into the
gcnciiil en dilation, 01 whethei the function of
the b\ei and the intestinal M!!I i,s to piexent
sugar passing into the geneial cii dilation, is a
disputed point which will be discussed in the
ai tide on the Incr functions
Pavy thinks th.it it sugai woie continually
being passed into the ujeneial cu dilation, the
mine would al ways contain sugai in quantity
He believes th.it «iuy excess of stii»ai in the
blood is alwajs eliminated 111 the mine
It has been shown, howe\ei, that the sugai
in the blood di.sappe.ns when the h\ci is excised
(Minkowski), 01 when the vessels of the hvei
are hgatuied (Boek and Hoftmann, Seegen)
IntiaNcnous injection of lame quantities of
sugai have not been followed by glycosmia
(Biedl and Kiaus) Also subcutaneous injections
of ceitam kinds of sugai — dextrose, l.vvulose,
and galactosc —were not followed by glyeosuna,
but aftei the subcutaneous injection of cane and
milk sugar, the \\hole of these substances was
found agun in the mine (Voit)
KXPLKIMEXIAL DlAKKIES AM) (iMCOSURl\ —
In this HI tide it is only possible to very bneflj
mention some of the moie impoitant lesults of
experiments on animals
C Beinaid picxluced diabetes by puncturing
the flooi of the fomth \entiicle It appears
probable that changes are thciebj pioduced in
hepatic cells, and that the impulses which cause
them pass along the splanchnic nerves By
other experimental lesions of the nervous system
diabetes may be produced, as, for example, by
division of the medulla (Pa\y), injury of the \ermi-
foi m pioccss of the cerebellum (Eckhard), injury
of various parts of the pons and posterior columns
of the spinal cord (Schiff), centrifugal vagus
irritation (Arthaud and Butto) Ptowy produced
diabetes by1 injection of dehhrmated arterial
(oxygenated) blood into the poi tal vein Diabetes
can also be produced both in man and animals
by the administration of phlond/m (v Mering)
Ahmentaiy, puerpcial, and symptomatic gly-
cosuria, as well as glycosuna pioduced bj
phloridzin and chemical substances, will be con-
sidered in the article on glycosuna.
PANCREATIC Di \BETBH — It was not until 1889
that it was found by Minkowski and v Meimg
in Germany, and by Do Domimcis m Italy, that
total extirpation of the panel cas in dogs is
followed by diabetes Paitial ex tn pat ion, / f
when one-quaiter 01 one-fifth of the gland is left
behind, does not produce diabetes E\cu when
the panci eatic duct is hgatuied and the lemam-
uiti piece of the pamicas has no conne< tion with
the duodenum, still diabetes does not follow
Minkowski has shown the relation of the pain leas
to diabetes by the most sinking experiment of
transplanting a piece of the gland and giafting
it undci the skin of the abdominal wall (exteinal
to the abdominal <a\ity) If the tianspl«uited
poitioii of panoeas (01^ giaft) does not neciose,
then di.ibetes will not occm when the whole of
the lemannng mtia-abdominal pait of the gland
is removed But if the transplanted poition
of pancreas be subsequently lemoMxl, then
diabetes occuis
It is piobable th.it Miiiicthint; is foimod in the
panel cas which passes into the en dilation and
hi ings about siii-ar destine tion, en pi events the
accumulation of siujar in the blood Lepinc
and otheis believe that this " Miiiu»thiii<r " is an
mtc'inal secretion of thi panueas, which is
al)B nbed by the pancreatic lymphatic s UK I \eins
[It is well known that sugar is biokcn up in
the muscles, picsumably by ferment-action, yet
no glycolytu fenncnt can be obtained fiom thorn
Oohnheim, liowcvci, has shown that if to muscle
juice the fluid expiessed fiom the pancieas be
.uldi'd, the mixture lias a maiked gljcolytu
powei which ncithei of its comfjoncnts possesses
sepal atcly It thus appears as thouirh the
internal secretion of the pancieas influences the
metabolism of sugar indiiectly, tin ough action
on the muscles ]
KnoLom AND EIIOLOOICM, llErAnovs — The
disease is moio common in males than females ,
the liability of the two sexes is about equal in
the eaily period of life, but after the age of 30,
males .ire moie frequently affected than females
The disease is moie common in adults In
private piactice it is most fiequontly met with
between the ages of 50 and 60, but in hospital
practice there is a larger propoition of voung
diabetic patients
The following table gives the age and ser of
100 cases of diabetes in Manchestci (mostly
hospital patients) —
AQE
IN \t
AR8
1020
2030
SO 40
40 10
0060
0070
Total
Males
Females
6
b
12
18
14
8
18
8
9
8
1
02
38
12
25
•22
•21
IS
8
100
DIAHETKS MELLITUS
323
The percentage at vauous ages recorded by
seveial authors is as follows —
(link
Si«epon
|L lif r Io J|J | M *' M w i 40 j° r>0 °° ti0 "°
i I IS J
10 I
11 '2 ! 2J 1 ' )')
16 I 21 j JO
7^!
The disease is compaiatncly late At the
Manchester Royal fnfii niaiy during the twont\
yo.us lK7.r)-9"> tho number of medical in patients
was 27,721, and oi these only 273 suflered fiom
diabetes, i e only 0 U per tent
In India, (Vyluii, South Italy, and Malta, the
disease is mm h moie common than in most
othei countnos In India it is nioic common
among the Hindus than the Mohammedans It
is said to be inoio common amongst the Jews, but
pi obably it is the w CM! thy Jew -> w ho chiefh siitfoi
The leports of the Registiai-Uenoial show
that in England tho moitaliU fiom the disease
is steadily incicasmi; A snnil n incieaso in the
moitality has been noted in Fiance, Dcnmaik,
and the "l mted States
l'Kl«nisroslN< AM) K\(IIIM. C'Absfcs —Some-
times thcie is i tamih/ In^toty of diabetes (l,i
pei cent) Biotheis 01 sistois oct.tsion.ilh
suft'oi , sometimes an tun le 01 aunt of the
diabetie patient/ has been similaily iifle< tod , but
it is \eiy i.iu* to hud that the [athei 01 mothei
has had the disease
Attei fjrfftnaf injuue-* tempoiaiy ylyiosuiM,
sometimes oceuis, and occasional 1} i line
diabetes tollo\\s It is evident that theie must
be some othei factoi in the c aus.it ion Still
sufhcn nt cases .ue now on iccoid to show that
pi obably an iiijiuv is sometimes the exutmg
cause (0 pei cent of diabetic patients) In at
least half of tho case s of tiaumatu diabetes the
head has been the seit ot the mjui}
NumeioLis sliikmg instances aie on lecoid in
which diabetes lui lapidly followed trn/ht,
pud fnt ywss/wt, 01 infntnf emotion . also in main
oases the syniplonis have followed piolonged
mental anxiety and wony, onvmu; to loss ot
money and loss of employment, etc (this
bistoiy obtained in 10 per <ent of cases)
Mental an\iet\ and ovei-woik associated with
the nui sing of a sick relatne, etc , is sometimes
an exciting cause (8 pei cent of cases)
Ohe^itfi is sometimes associated with a mild
foim of diabetes in individuals between the ages
of 40 and 60 In young poisons occasionally
gtcat obesitv is followed by a severe foim of the
disease (Oreat obesity pieccdod diabetes in 1
per cent of writoiV) cases )
Gout may bo associated with diabetes which
is usually of a mild form Such cases are met
with chiefly in private practice and are laie
amongst hospital patients
A marked history of alcoholism (chiefly beer-
drinking) is sometimes obtained (17 per cent of
cases), and probably this is an occasional cause
of the disease
An attack of inmion/a, .in acute fcbule
affection, pneumonia, bionchitis, pleurisy, ex-
posure to wet and cold, the drinking of cold
fluid when the body lias been vciy hot, and
injury fiom a lightnirg stroke, have been
legal dod as occasional exciting causes of the
disease (Diabetes developed dnectly aftei an
attack i)l influenza in H pei cent of eases
collected by writer) It is possible that in a
tew cases syy>////>s miy be an indirect cause of
diabetes In pioduiing ceiebial or pancreatic
lesions
Occasionally diabetes follows pt ft/navr y or the
development of an abscess of the In oast (7 pei
< cut ot wntoi's tases) Occasionally diabetes
develops during pi ej> nancy, but ceases with tho
Icrnniation of the latter, to incur at a later
d.ito It has been thought by some wntcrs that
the dim ictoru peuod favours the occurrence of
diabetes in women In at least 1.") per cent of
the eases no In \tmifnt tint/ crcitiny cauw can be
obtained
Rn \IION 111 1 \\fclA DlVHKIhs MEI L11US \M>
DisLxsps oi MIE LiXLii Kiom the results of
physiologic il ovpenments, one would expect
that theie would be some clear relationship
between diabetes and pathological changes in
the livoi but no definite 01 constant patho-
logical ( hani;c is met with in the luci m
diabetes, though this oigan is sometimes
diseased In 20 cases in Manchester, tho livei,
as ic!>ards si/e, was enlaiged in 11, diminished
in 4, and noimal in ."> Tn one of the cases
multiple abscesses woie picsent, in another
theie was cmhosis, in anothci fatty infiltration
and cnrhosis, in .inothei fatty infiltration and
congestion In the othei cases, beyond vana-
tions in sue, tin only change was congestion,
which was often piesent These are the most
common abnoimabties , they aie not constant,
and uc \ 01 y often met with unassocuitcd w ith
•liabctes
Tho ulyiogon in the h\er cells K»nioved by a
hue tiocai dunng life was in one case considci-
able, but in inothei case it was absent (Klulich)
At piesent jwt/tottn/ic<i? anatomy does not fui-
nwh any OMdence th.it di.ibetos is related to
hepatic changes
Itar trios uLrwEBN I)i \UBTES AlELiirus AND
AriFnioNs or IHE XKKVOUS SYSTEM — It has
boon ah evilly mentioned that diabetes has often
followed gie.it mental anxiety, worry, or sudden
fright, and thcic arc many points in favour of
tho connection of diabetes with some change in
the noi xous s)stem But important pathologi-
cal lesions ha\e been mot with in only a small
pioportion of cases *
Tho changes uaually recorded are slight, and
such as aio frequently met with when no symp-
toms of diabetes have boon present during life
A number of cases are on record, however, in
324
DIABKTKS MELLITUS
which cerebral changcb have been found post-
mortem, that have probably been the cause of
the diabetic symptoms. In 30 of such cases
recorded m literature, there was a tumour in
the floor of tho fourth ventiicle in 4, other
changes at this region (such us softening, fatty
degeneration, scleiosis, hamioirhago, cysticcrcus)
in 14, tumour of the medulla in 3, lesion at tho
base of the brain (turnout, softening) in 3,
tumour of the pituitary body 1, cysticeicus in
cerebellum 1, softening in cerebellum 1, cerebral
tumour (tempoio-sphcnoidal lobe) 1, tumour
compressing right vagus nerve 2
In 14 consecutive cases recently examined by
the writer, the medulla and othei parts of the
brain appeared normal m 9, in 5 naked-eye
changes were found In the latter cases tho
changes were the following cyst of the cere-
bellum close to the right vagus loot in 1,
cerebro-spmal meningitis (probably secondary to
hepatic abscess) in 1, minute hwmorrhagic
patch m left vagus nucleus m 1, tumoiu ot the
pituitary body in 2 (m those t\vo cases symptoms
of acromegaly m addition to those oi diabetes
were present during life)
Careful microscopical examination of the
medulla has been made frequently, but usually
\vith negative results The minute excavations
around the cciebial ai tones descnbed by Dickin-
son are no\\ genoially believed to be duo to
the effects of hardening Ficiichs descnbed a
marked dilatation of the small vessels of the
medulla, and this he legaided as the most im-
poitant and constant change m the nervous
system in diabetes Of 10 cases oi diabetes
examined microscopically by the \vntei, the
medulla appeared normal in 4, in 1 thcie \vas
puiulcnt meningitis , m 5 cases the blood-
vessels of the vagus nuclei were much dilated
In 3 oi the lattei 5 cases theie were small
hemorrhages present m the ^agus nuclei, twice
unilateral, once bilateial In one oi the cases
the hwmoiihagic patch could be seen with the
naked eye
Though tho examination of the medulla often
yields negative lesults, it is still possible that
minute or functional changes may bo present m
the nerve cells of the \agus nuclei, or at other
part of the medulla, which cannot be recognised
at present by microscopical examination.
The spinal cord is usually normal, or presents
changes which arc to be regaidcd as secondary ,
but m a very few cases gross lesions have been
found which may have been the primary cause
of the symptoms (tumour 01 softening of tho
cervical region)
The sympathetic nerves and ganglia (cervical
and abdominal) have been carefully examined
by Hale WMto and others, often they have
been normal, and when changes have been found
they have not differed from those which have
been frequently met with when there have been
no diabetic symptoms during life.
Occasionally a mild glycosuria occurs in
association with well -marked disease of the
nervous system, such as locornotoi ataxia, dis-
seminated sclciosis, Giaves' disease, etc But
the association of a well-marked diabetes with
these affections is very lare.
DIABETES AND ACROMEOALY — During the last
five years a number of cases of acromegaly have
been recorded m which glycosuria was present*
and in some of the cases theie has been a well-
marked diabetes (2 cases of diabetes associated
with acromegaly have come under the writer's
obseivation) Out of 21 cases of acromegaly
recorded in literature, 4 were associated with
true diabetes, 2 with glycosuria, and m 15 cases
the uiine \vas free from sugar In acromogaly
a tumour of the pituitaiy body is usually
piosent, and cases of tumouis of the pituitaiy
body are on leeord m which diabetes has been
pre^nt, but symptoms of acromegaly absent
THB LlELATION OF DIAUE1K8 10 LhSlONS OP THE
PANCREAS — Changes in the pancreas have been
desciibcd fiorn time to time, ever since Cawloy
iccorded a case of diabetes (in 1788) in which
tho pancreas \vas ati opined and contained calculi.
Many yeais ago Lanceieaux drew attention to
the panel eatic lesions
In 24 consecutive cases oi diabetes examined
pathologically by the wntei, the condition of
the panci eas was as follows —
Casts
(a) Kxtcnsi\o changes (very maiked cir-
rhosis 2, cancer 1 , extensive atrophy I ) 4
(It) Well-maiked changes (cirrhosis 2, hpo-
matosis 1, atrophy with fatty de-
gcnciatiou and inhltiation 1) I
(c) Slight changes (attophy \\ith slight
fatty degcueiatum 1, atiophy out of
proportion to the geneial wasting 2) 3
(rf) Atiophy, but only in ptopottion to
the general \\asting 5
(e) Pancreas normal, macroscopically and
microscopically 8
21
In the uist 4 cases of the above table tho
pancreatic changes were so extensive that, beai-
ing in mind the lesult of total extirpation of tho
gland m animals, theie can bo little doubt that
the diabetes was due to the pancieatic lesion
In tho second group of cases it also appears
piobable that diabetes was due to the pancreatic
changes , m the third group the relation is un-
certain, and m the last two groups of cases
eithei tho diabetes was not dependent on the
pancreatic disease, or the pancreatic affection, if
present, \vas a functional one which could not
be recognised macroscopically or microscopically.
Many cases of diabetes associated with pan-
creatic disease are now on iccoid, and various
extensive changes have been found, such as
ciirhosis and fibroid changes, fatty infiltration
DIABETES MELLITUS
325
and degeneration, calculi, cancer, cysts, and
marked atrophy Often the pancreatic tissue
lias been almost absent owing to the changes
mentioned
It 18 veiy mipiohable that all these \ancd
pancreatic changes should be the result of
diabetes, and when wo consider the lemarkablo
results oi experimental lemoval of the pancreas,
it appears very piohahle that, in ccitam cases,
diabetes is directly due to pancreatic disease
Theie are t\vo objections to the p.iu< rcatic
theory of diabetes in man The firwt is that
ylycosui to, ?*. absent in many casei of diseases of
the pancteu* But it is irnpoitant to remember
that in extiipotiuu of the pancicas m annuals, |
if a small poition of the gland should be left I
behind, no diabetes follows And in IOHII, m I
disease of the panel eas, often only a poition of I
the gland is affected '
The Hcc-ond great objection to the pancicatic
origin of diabetes is the fact that the jmnnea^
is not afffttd in nil <ast'\ of diabete* In one-
thnd of the cases the pancreas is normal macro-
scopically and micioscopually Hence in these
cases oithei the lesion causing the diabetes is
not in the pancreas, or the pancieatie affection
is a functional one
It is conceivable that aiteiiu-scleiosis may
cause diabetes by pioducing changes in the
pancreas 01 in the HCMOUS system, and several
instructive cases of diabetes an1 on recoid in
\\hieh maikcd pancreatic changes \\eiG found
post-moitem that \\eie appaiently the result of
aiterio-scleiosis
[The conflicting statements which h«uo been
made concennng the tel.ition of panel eatic
disease to diabetes ha\e now been to a Luge
•extent re(oncctcd bj the uoik of Opie and
otheis Thcio is good UMSOU to believe that
one pancreatic IUMOU, find one only, has the
power of so influencing the action of the internal
secictionof the organ on caibohydi ate metabolism
that glycosui M i esults, and that is disease of the
ductless islands of Langeihaus These bodies
aic mvohed in intoiaciuar pancicatitis, not in
the inteilobular foim, and only \\hen then cells
arc imaded, \\hethei by this pioces*, be it
primary or secondaiy to aitciio-scleiosis, hepatic
cirihosm, or cancel, or by some lesion in \olvmg
the whole pancicas, does diabetes icsult ]
DIABETES or KVDOOKVOUS ORIGIN — In many
cases of diabetes the most careful inquiry fails
to reveal any exciting cause, and often the most
careful examination of the brain, pan ci eas, liver,
and other otgans fails to icveal any changes
except what aic secondary or accidental
It is quite possible (as suggested by Strumpell)
that some cases are entirely or almost entirely
endogenous in origin, i e they are due to some
developmental al uiormahty
SYMPTOMATOLOGY
In the severe forms of diabetes tho face- is
often wasted in appearance, the v\ tinkles and
naso-Iabial folds are well marked, and the ex-
pi cssion is often anxious or sad But the face
and lips aic not anamnc, 01 not markedly
anamnc, unless some complication should lx>
present In tho mild forms of the disease, how-
ever, the facial expression is not characteristic
In severe fonns of diabetes waittny is a
piommcnt symptom, especially in young persons,
\\hilst in cldeily patients mild diabetes is often
associated with obet>ity
ONSET —In many cases thiist and dmte»is are
tiic hrst symptoms noticed, sometimes the
eaihest sign is tioublesomo ctampi in the calf
muscles at night In othci cases the patient
fust socks medical advice on account of wasting
and met easing veaAwes*, or on account of one of
the complications (gangicne, carbuncle, cataract,
of 7rma of the genital organs, etc ) Occasionally
the patient states very definitely that the thirst
commenced suddenly on a ceitun day, and at a
certain horn Sometimes a ^cry slight glyco-
sui u, unaccompanied by thirst, diuiesis, 01 other
symptoms, has preceded the tiuo diabetes for
months or \ears, but eoitamly this is not
always the case
THE THINE — The tfwmttty of urine is m-
ci eased (often 150 to 300 ounces in the 24
houis), but in many of the milder cases the
increase may only be slight (00-100 ounces
daily)
The unount of mine is about equal to the
fluid taken It is i educed by a nitrogenous
diet and by internment disease, and often
diminishes befoie a fatal teimmation The
infant of the in mo is veiy pale, geneially light
yellow or stia\\ colouicd , often, but not ahva^s,
it has a rpcfn nh- yellow tint Hut when tho
amount of mine is not me leased, in the mild
foims, the colon i may be noimal
A mucous cloud, when piescnt in diabetic
mine, is often seen, not at the bottom, but at
the upper pait of the mine glass Diabetic
mine is usually bnght and clear, but sometimes
in female patients it is tuibid fiom the presence
of pus and epithelial cells The smell is often
M\ ect or aromatic , and in severe cases, especially
just before the onset of coma, the mine has a
peculiar "chloioform" smell, usually attnbutod
to the piescuce of acetone The taste of diabetic
urine is sweet The reaction is nearly always
acid, and often maikcdly acid The vpecijic
Cavity is increased (up to 1030, 1045, or highci)
A small quantity of sugar may be found, how-
ever, in in me of a normal or low sp gr.
The presence of svt/at is of couiso the most
important change in the unno in diabetes.
Sometimes before the patient ha^s been awaro
of the nature of the disease he has been struck
by the fact that flies have been attracted to his
urine , also, if a drop of it has fallen on to his
boot, or any adjacent object, and has been
allowed to dry, he has observed that ft salt-like
326
DIABETES MELLITUS
deposit has been left behind The sugar piescnt
in diabetic urine is grape-sugar (glucose), and its
amount varies accoidmg to the nature oi the
case from 0 5 to 6, 8, oi 12 per cent The daily
amount excreted may be 3000 to 1000 giains, 01
more (For sugar testa see ai tides on "(Jljco-
suna " and " Ui me, Pathologic.il C 'hanges ") The
sugar increases in mild cases aftei food, and
diminishes during fasting, and hence the cxcio-
tiuii is less dutmg the night In very mild cases
sugai may be absent in the night urine (passed
bctore bieakfast), whilst it is abundant in the
day mine The sugai excietion is mci eased by
starchy and sacchauno f<x)ds, and diminished by
nitrogenous diet In mild c.ises, when caibo-
li yd Kites arc withdiawn horn the diet, the sugai
disappears fiom the mine, but ictmiis when
caibohydiates are taken again In the mildest
cases simple restiiclion of the caibohydiates is
sufficient to cause the glycosui'a to disappear
These are points of prat tical importance in urine
testing in mild cases In severe cases of diabetes
sugar is present in the mine in spite of the with-
drawal of all carbohydiate fowl, and may be
present during fasting
Sugar is the caibohydrate in the diet which
causes glucose to be eliminated in the gieate&t
quantity in the urine, whilst staith and othei
caibohydrates aie less mjmious (Jrapc-sugai
is most injurious , fnnt-sugai (lEcvulose) is onlj
about half as injurious as grapc-sugai , milk-
sugar and cane-sugai stand midway between
gi ape-sugar and hevulose Fats nevei inciease
the sugai excretion, and alcohol in modciate
quantity has no effect
Jfiivculai eterctw diminishes the sugai cxcie-
tion in well-nounshcd patients suffering horn a
mild torni or eaily stage of the disease But
when the affection is sc\eie, and the patient
wasted, exercise increases the sugai eviction
The sugar excietion is often <1tnuni\h«l en
a netted by mtei current aflections
The excietion of uiea is increased owing to
the excess of nitrogenous food taken by the
diabetic patient , only in a few ( ases is the in-
creased urea cxuetion due to the flesh notion of
the albumen ot the body (Seegen)
Not infrequently thcic is a small deposit of
uric and crystals at the bottom of the mine
glass m mild cases of diabetes
The excretion of tutnnonia is increased in some
cases, but not m all In diabetes coma it is
gioatly mci eased Sometimes there is an
abundant deposit of oxalato of lime
At the early stage of the disease alluminm ia
is usually absent, but it frequently appeals at a
late stage of the disease Thus in 100 cases
the wutei found albumen piescnt m 30 when
the patients *h ist came under observation, but
in some of the cases in which albu minima was
absent at fiist it developed later, so that finally
it was present m 44 per cent The albunnnuiia
is usually veiy slight, and not associated with
nephritis or any gross lesion of the kidneys,
but in a few cases the albummuria is abundant,
and there aic signs of parent hymatous 01 intei-
stitial nephiitis In only 4 out of the 100 cases
of diabetes just mentioned \vas the amount of
albumen Lugo In diabetic coma albumen and
casts arc neaily always present in the mine,
but otheiwise the nlbunnnuiia is not accom-
panied by casts, except m the laie case when
theic .lie indications of actual nephiitis
When inflammation oi the piepuce oi of the
Milva is present as a complication, the in me,
when letently passed, often contains fungus
spoies and myeelia along with a few pus cells.
In diabetic females the mine is not mfiequently
slightly tin bid, owing to the piesence of pus and
epithelial cells
In the scvcic foims of diabetes, when a solu-
tion of pcichlonde oi iron is added to the mine,
there is at hist a tuibidity owing to the precipi-
tate of phosphates, but on adding moio of the
penhlonde solution a daik bi ow uish-i ed coloi.i-
tion is often obtained This coloiation is known
as Geth<n<lt\ mutton, and is usualh attributed
to diacetu acid , by some it is attubuted not to
this substance, but to othei dosel} -allied com-
pounds This leaction is an indication of a
se\eie foim of the disease , it is usually piescnt
in diabetic coma, but m mild terms of the
disease it is absent A similai leaction is oc-
casionally met with in febule diseases and several
othei aflections Also the in mo oi patients who
tiie taking salol, salicylic acid, and bahcylate of
soda gives a daik, biownish-ied coloration with
peichloiide of lion, but the coloui has more of
a Molet 01 purple tint than that obtained in
sevcio cases of diabetes The mine of patients
taking an tip} nn, salary rin, and se\eial othei
dings, also gives a brownish-led coloiation with
peichloiide of non When the in me of a diabolic
patient gives a reaction with pci< hloiido oi non,
often acetone is also piesent It ma} be detected
by Lcgal's test To se\eial (c ol mine a tew
diops of a concentiated, ficshl} made solution
of nitro-piussulc of sodium aie added The
nnxtuie is made alkaline with IUJHOI potassie,
and then a<eti< acid is added when a violot-ied
coloiation is obtained Anothoi method is to
distil about half a litic of urine , to the distillate
a few diops of a solution of iodine in iodide of
potassium, and a few drops of caustic potash, HIC
added When acetone is piesent a piccipitatc
of lodofoim occuis It is yellowish in colour,
and has the chaiacteiistic lodofoim smell, undei
the micioscopc it piesents hexagonal plates or
stais It has been shown that acetouuria may
l)e pioduced in healthy persons by a diet of
mtiogonous and fatty food, free from caibo-
hydiates, but on the .iddition of caibohydiates
the acctonuria disappears (Hnschfcld, Rosen-
feld, and others) A high dcgicc of acetonuna oi
an increase of the acetone excretion is legarded by
Hirschfcld as an indication of approaching coma.
DIABETES MELLITUS
327
In the sin ere foims of diabetes /3-oxybutync
acid m often found in the mine
TUB BLOOD — The most important change in
the blood is the excess of sugai piesent A
minute quantity of sugai is picsent in normal
blood (06 to 1 0, or a little mote than 1 0 pel
1000, Pavy , average in ten healthy men, 1 7
per 1000, Seegen) In diabetes mellitus the
amount of sugar in the blood is usually greatly
iiiu eased, and may reach 2 7 to ."> 7 pei 1000
The wntci has disco veicd a simple method oi
distinguishing diabetic blood ftom non diabetic
blood by its leaction with a solution of metky-
lene Mite. This method is extiemely sensiti\e,
and it is only necessai) to examine a diop of
blood obtained by pricking the hngei On heat-
ing a diop of duhetu blood and an alkaline
solution oi nicthylenc blue in <ut<un piopoitions
the blue coloui of the solution is ipuumnl, \vlnlst
if non-diabetic blood be used in place of diabetic
blood (in the vuitejnojiottton) the solution letams
its blue coloui
The test may bo pei foi mod as follows —A
small, tun tow test tube is well cleaned, and a
diop of watei (40 uibtc nttf/inutte\) placed at
the bottom It is important to use a naiiow
test-tube so that the uppoi smface of the lluid
\\ith which the an (ouies in contact may be as
small .is possible To measuic the quantity of
blood the capillaiy tube oi a (Joweis1 hremo-
glohinomctei whuh is graduated foi 20 tufm
miltimitit* may be used The tip of one of the
patient's tinge is is (leaned and diied, and then
pncked When a laige diop of blood h.is escaped
it is sucked up into the capillaiy tube Twent)
<nl»n iiu/lititifns of blood are taken fiom the
iingei The blood is blo\\n gentl} into the
wate.1 at the bottom of the small test- tube
Then 1 tulm trntunt'tte (/ i 1000 t ubtt uitltt
j/jrfj(s)of a \\iitei > solution of meth}lene blue
is adiled The stiength of the meth\leue blue
solution is 1 in bOOO (To measmo the mcthy-
lene blue solution the I cc pipette tube of
Southall's uieometei may bo used ) To the
mixtuie of blood and metlnlene blue in the
test-tube finally 10 titbit int(ltnutu't> of liquoi
potass.e (BP) ate added The fluids in the
tube die then well mixed by shaking As a
eontiol experiment a second test-tube of similai
sue is taken, and into this is plaeed the same
quantity of non -diabetic blood \vith the same
piopoition oi watei, methodic blue, and h(|uor
potassce
The fluid in e.uh tube has a fanly deep-blue
coloui Both small tubes are then placed in a
beaker, capsule, 01 veiy \vide test-tube contain-
ing \\atci Heat is applied by a spnit lamp
until the watei boils It is allowed to continue
boiling foi about four minutes By the end of
this time tho fluid in the tube containing the
dial>etic blood changes its coloui from a fairly
deep-blue to a duty pale yellow (almost the
colour of normal urine), whilst the fluid in the
tube containing the non-diabetic blood it mams
bine Occasionally it becomes bluish - gieen,
sometimes violet , but it nevei loses its blue
coloui The tubes should be kept quite still
whilst in the water-bath, as by shaking the
decolorised nicth^lene blue is apt to be oxidised
by the oxygen of the atmosphere, and a blue
tint may then leturn to the fluid This is the
teason why it is necessary to employ a watei -
bath, since if the test-tubes be heated dnoctly
ovei a spnit lamp it is diilicult toa\oid shaking
the fluid
A milky appeal ancc oi diabetic blood has
occasionally been obseixed on post- moi tern
examination In othci casc& the bloud has had
a pink coloui, and on standing a milky or cream-
like seium has sepaiaUd on the MII face This
en am like condition of the soium has been
shown by mieioscopual and chemic d examina-
tion to be due to the piescnce ot iat globules
Analysis of the blood lws sometimes sho\\n that
the pei cen tage of fat has been me leased
MMl'lOMs, ('OMPIICAIIOXS, AM) PAIHUIOCK AL
ClIANbKS IN CONNLC1IOX \\1IH I HE \AHlOUs
S\SIMIS — Besides the changes in the uime
other prominent sj mptoms ate — thnst, increa-ed
.ippetite, gieat weakness, and emaciation in the
seveie forms of the disease, a liaihh diy skin,
often a led, ia\\ -looking tcdiguo The tcmpeia-
tuie is noi m.il 01 subnoimal except \\hen com-
plications occui
AIIMF\IAII\ CANAI, LI\FK, AMI PAXCHLAS —
The Kiln a is usually v(,int\ .ind the mouth dij
rriie gums ,11 e oiten inflamed, spong}, and
swollen The teeth aie often canons, and be-
come loose .ind fall out Thnst is one of tho
most chaiacteiistic* s\ mptoms of the disease, and
often cnoimous quantities of fluid aie taken ,
but in "\eiy mild cases the tlnist is slight oi
absent , and also in se\eie cases dining the last
fe\\ days ot life the thnst often diminishes or
ceases, when phthisis 01 othei complications ha\c
developed Tho .ippetite is geneially inci cased
gieath, but this is not siuli a constant s^m]>toiii
as thnst In ceitun mild cases the appetite is
not inci eased , also in sc^eie cases at a late
stage the appetite fails
Diabetic patients \eiy fiequently suflfoi fiom
constipation In c lit onic cases dianhaa is occa-
sionally piosent
Pathological examination does not icxeal any
clwiactenstic change in the stomach or intes-
tines Occasionally tubeiculous uheiation (f
the mtestmoh has been met w ith Tho patho-
logic al changes in the hvei and pancieas have
been alieady lefeited to
THF LUNGS — The most fiequent pulmouaiy
complu'ation is tuboiculai phthisis It occms
moie ficMUiently in joung diabetics, and in the
seveie foims ot the disease amongst the pool
In cldeity diabetics, especially in the obese or
gouty, tubeiculosis is much less ficqucnt
In 100 consecutive cases (chiefly hospital
328
DIABETES MELLITUS
patients) in Manchester there were evidences
of phthisis in 29.
Next to coma, tuberculous phthisis is the
most common termination of diabetes In half
the cases of diabetes in \vhich the w liter has
seen or made an autopsy, tuberculous disease of
the lungs (extensive or slight) has been present
The phthisis of diabetic patients is usually tubci-
culous, and tubcicle bacilli aie ptoscnt in the
sputum
Phthisis in diabetic subjects generally runs
a compaiativcly latent couise, and the patho-
logical changes aie moie advanced than is
suspected from the clmual signs Cough and
expectoration aie often slight The tempera-
tuie is not much abo\e noimal, and hemoptysis
is very ran* But to these gcncial statements
there aie exceptions When the lung changes
become advanced the diabetic symptoms giadu-
ally subside, and finally the sugar may disappear
from the urine
Pathologically diabetic phthisis is usually due
to a chronic caseous tuberculous broncho-
pneumoma, it generally runs a rnpid course,
oaseation soon occurs and the diseased parts
break down and cavities are formed There is
no tendency to cicatrisation
Occasionally a chr<nu< pncunumtc (non-tubei-
culous) phthisis is met with in diabetic subjects
Gangiene of the lungs occasionally occuis as
a complication , in sueh cases the characteristic
offensive smell of the sputum may be absent
Broncho-pneurnonia and acute cioupous pueu-
moma are rare complications
THE HEART — Usually theto are no signs of
cardiac disease, especially in the severe foims
of diabetes (lleait noinial on clinical examina-
tion in 93 out of 100 cases examined by the
writer.) In the later stages of the disease the
heart's action and the heart sounds are often
feeble.
Mayer of Carlsbad has found caidiac enlarge-
ment in 216 per cent of the cases (but piobably
a considerable piopoition of his patients would
be eldeily persons suffering fiom a mild form of
the disease)
Occasionally diabetes tci inmates with symp-
toms of cardiac failure or collapse (see " Diabetic
Coma," p 329)
The pulse is usually noimal, but in elderly
persons often signs of arteiio-sclcrosis and high
tension are met with , and sometimes the pulse
is large, hard, and of increased tension in diabetics
under middle life, even when thcie are no evi-
dences of kidnoy disease
Pathologically in severe forms of the disease
the heart usually piescnts no macroscopical
change except general atrophy, or the heart
muscle is often soft and flabby. Israel, how-
ever, found caidiac hypertrophy (generally asso-
ciated with hypertrophy of the kidneys) in 10
per cent of the cases of diabetes examined patho-
logically at the Berlin Pathological Institute.
Sometimes fatty or glycogenic degeneration
of the cardiac muscle is found on microscopical
examination
TUB KIDNEYS — Albumen, usually in small
quantities or meie tiaces, is often present in the
mine of diabetic patients (44 per cent oi cases).
It occurs especially at the late stages of the
disease, and is not associated \\ith nephritis. It
has been attubuted to excess of nitrogenous
food, to catanh of the bladdei, and occasionally
it is due to the mixture of a little pus with the
nnne owing to the balamtis in the male, or
eczema of the vulva in the female. In a few
cases the albumen is laige in amount, and is
associated with signs of iiephntis, parenchyma-
tous or intoistitial (4 out of the 44 cases of
albummuria just mentioned)
On pathological examination hypertrophy oi
the kidneys is not uncommonly found. Occa-
sionally theie aie signs of mteistitial, pareu-
chymatouH, 01 diffuse (paienchymatous with
interstitial) nephiitis, and in a fc\\ cases tubeicle
of the kidneys Micioseopieally changes in
the renal epithelium aie often piesent, and
the following have been dcsciibcd — hyaline
degeneration (Aiinanni) , nociosis of epithelium
(Ebstem), fatty degeneration (Fiehtnei); glyco-
genic degeneration (Elulich and Fierichs) The
latter change is met with chiefly in the cells of
Henle's loop.
THE SKIN — In seveie cases the skin is usually
(by and lough, but in the mildei cases it is
generally noi mal Prmitus IN sometimes trouble-
home, it is usually local, i ai ely general Pruritus
is most common about the genital oigans, especi-
ally in females, and sometimes it is the symp-
toms foi which advice is first sought Piuiitus
of the vuha is piodural by the imtation of
the bacchaime mine, it is often followed by
erythema and cc/ema In the male pruritus of
the glans penis is due to the same cause, and is
often followed by ciythema and balamtis, and
the piepucc may become ojdetnatous
Boils and carbuncles sometimes occur, the
latter aie most frequently met with on the nock
In patients ovei 45 gangrene sometimes occurs
It may be moist 01 dry, and is frequently asso-
ciated with ai tor 10- sclerosis It occuis most
fiequently in the foot, and is often excited by
some slight wound or injury to the skin Gan-
grene may follow celluhtis in other parts.
Perforating ulcers on the feet resembling
those seen m locomotor ataxia are occasionally
met with in diabetics over middle age.
Anasarca of the feet and sometimes of the
hands, without albummuria 01 signs of caidiac
failure, is an occasional complication of diabetes.
Xanthoma diabcticorum is one of the rarest
skin affections m diabetes
Other skin affections are occasionally met w ith,
and recently a form of diabetes with bronzing
of the skin has been described (diabtte bronzt)
AFFECTIONS OF THE EYE —Defects of vision
DIABETES MELLITUS
329
are not uncommon in diabetes The mobt im-
portant affection is cataract (9 per cent of cases)
It is usually bilateral, and occurs m young
patients as well as in the aged. It is generally
of the soft variety, but not invariably
Defects of vision aie also caused by paresis of
accommodation, .shortsightedness developing late
in life, vitreous opacities, retimtis, and amblyopia
Diabetic retnntis is very rare (seven cases in 100)
It only occurs m patients over the age of 40
In one form of diabetic retmitis the changes con-
sist of small puuctiform hocmonhages scattered
over the retina In another form the changes
consist chiefly of small white patches chiefly near
the centre of the retina These white patches
have a " curdy " appearance, and are sometimes
clustoied together in the form of a semicircle or
incomplete cncle surrounding the yellow spot ,
they are novel grouped in a star-shaped form
radiating from the yellow spot as in albummuric
ictmitis
Occasionally diabetic patients suffci fiom
amblyopia \\ith defect of vision chiefly in the
centre of the field and with central scotomata
forcolourb Ophthalmoscopic examination reveals
no changes in the disc 01 retina, «ind the condi-
tion resembles tobacco amblyopia
SBXUAT, FUNCTIONS — In the male, diminution
or loss of sexual power is not infrequent In
female's the sexual desnc is s,ud to be diminished
greatly in sevcic cases, whilst in the mild forms
of the disease in elderly women it us said to be
increased Anienorrhoea sometimes occurs at
an eaily stage Piegmmt diabetic women oiten
abort, and (lining pirgiwiicy and the pueiperal
state the disease often advances maikedly
NERVOUS SIHTEM — Mental dulncss and di o\\ si-
ness are frequent Often the patient is melan-
cholic and depressed, but as a iiile the intellect
lemams clear up to the last The writer has
recoided two cases m which changes were present
in the posterior columns of the cord in diabetic
patients In both cases the changes were seen
clearly with the naked eye After hardening in
Muller's fluid the degenerated tracts \\cie puler
in colour than the rest of the white matter , in
both cases they occupied Coil's columns in the
cervical region, they extended into Burdach's
columns in the dorsal legion in one case, m the
lumbar region in the other Micioscopitalh the
changes were much loss distinct, and consisted
in slight degeneration of the fibres of the pos-
terior columns Probably they were the result
of the diabetic blood condition * Similar changes
have been recoided by several observers Ci amps
in the calves of the legs at night arc common
in diabetes, and are sometimes amongst the
earliest symptoms of the disease The patient
may also complain of gnawing pains m the legs,
which may be so tender that he cannot bear
one leg to lie over the other in bed. The legs
may feel numb, and the knee-jerks in such cases
are often absent These symptoms are probably
due to slight peripheral neuritis. Occasionally,
but very rarely, there are well-marked symp-
toms of peripheral neuritis — the feet l>emg
"dropped" and the legs paralysed, and sensory
symptoms being present as in ordinary alcoholic
neuritis Cases are on record of monoplegia and
of paralysis of single groups of muscles which
are probably of neurotic origin
A small number of cases have been published
in which pathological examination has verified
the diagnosis of peripheral neuritis (parenchy-
matous form) In most of the cases recorded
the neuritis has occurred in patients over the
age of 50, and this complication docs not bear
any relation to the amount of sugar in the urine
The knee-jet h are not infrequently lost in
diabetic patients, and in such cases there are
sometimes slight signs of neuritis (gnawing
pains in the legs, tenderness, and cramps in the
calf muscles) , veiy rarely there aie marked
signs of yeriplteral neutiti* But frequently
when the kncc-jeiks are lost there are no other
indications of neuritis, and pathological exam-
ination may ie\eal no changes in the peripheral
nerves Amongst 100 diabetic hospital patients
the writer found the knee-jerks both lost in 49,
both present in 45, one pieseut, one absent in
6 Most of these patients sufteied from a very
severe form of the disease, with great wasting
In private pi act ice, where most of the mild
forms and eaily cases aie met with, the knee-
jerks arc only lot»t in a small proportion of case*
The knce-jeiks when piescnt at an early period
are frequently lost Liter Dining the last few
davs of life the writei found the knee-jerks lost
11/73 per cent of hospital cases, and the.) were
lost in 20 out of 23 cases of diabetic coma In
the severe forms of the disease, \\hen the knee-
jeiks ha\o been absent, the \\ntei has usually
iound the wrist-jeiku also absent But the
superficial reflexes — plantar, abdominal, and
epigastric — are general!} readily obtained 01
increased, even when the knee and wrist jerks
are absent
DIABETIC COMA — The most fiequent ter-
mination of diabetes IN in coma, which is not
dependent on any gioss lesion of the organs
When advanced phthisis is piescnt as a com-
plication, usually coma does not occur, but to
this rule there are exceptions
Diabetic coma may occni in all foims of the
disease and at all ages, but it is especially
common in young patients and in the severe
forms Coma may develop at a \ery early date
after the onset of diabetes, especially in young
people (few weeks or months), or it may only
occur after the disease has been present for
yoais. Coma has fiequently developed directly
after a long railway journey G&at muscular
exertion, gieat mental worry and anxiety are
also exciting causes A sudden change of diet
and a very rigid diet are thought by many
(Ebstein, Naunyn, Schmitz, Grube, etc.) to
330
DIABETES MELL1TUS
favour the development of diabetic coma w hen
the patient is suffering fiom a severe form ot
the disease, and when the urine gives a marked
reaction with perehloiido of non Piolonged
constipation is probably <i picdisposing cause,
and numerous cases are on lecoid in which
various complications and also smgical opera-
tions have appealed to be exciting causes
The symptoms of dtaltetic coma often com-
mence with lassitude, epigastric pain, nausea,
and occasional vomiting in other cases shott-
nesh of In oath is the earliest symptom, and it
has occasionally pieceded other s)inptoms foi
seveial dajs Headache ma} occur at the
onset Often the patient is anxious, testlcss,
ot excited at first, then drowsiness gradually
develops and passes into coma The pulse
becomes rapid and feeble, and Lcpinc regards
i.ipidity of the pulse as an important eaily sign
of commencing coma Dyspncea is a pi omment
featuio m the nuvjouty of cases, and the breath-
ing has a peeuhai panting 01 sighing character ,
the numbet of ic&pirations per minute is often
only slightly increased 01 even normal, and the
dyspnu'a is often indicated by deep mspiiation
and deep expiration, rathci than by much m-
riease in the frequency of rcspuation This
pccuhdi dyspnuua is dcsciibcd by Kussmaul as
air-hungoi The bowels aio generally con-
stipated The skin becomes pale and cold ,
and in many cases there is slight cyanosis of
the nose, lips, cats, hands, and tect The tem-
peiature is gcneially subnoimal, 9.V-97' T , in
a feu cases it uses at the last to 102°-1(H F
The bie.ith has usually a pecului smell, some-
what like chlotofoim, and acetone has been
ton tul m the cvpiml an This smell is often
detected foi some time befoie the onset of
coma
The acidity of the urine is mu eased, but
the quantity of mine and the amount of sugai
cxcieted usually diminish \\ith the onset of
comatose symptoms The mine, like th<
breath, has a peculiar "chloroform" smc-11
(acetone) A trace 01 small quantity of albu-
men is usually piesent (according to some
wnteis invanably present) in the mine in the
common variety of diabetic coma Sometimes
the urine is free fiom albumen up to the onset
of comatose symptoms , but in other cases a
tuuo of albumen is piesent for some time betoie
coma develops In 20 consecutive cases ol
diabetic coma the \\iitei found a trace ot small
quantity of albumen in the mine in evety case
Accouhng to Kulz, casts 1110 always piesent m
the mine in the common form of diabetic comu,
and he believes the appearance of casts to be a
valuable premonitory sign of the onset of coma.
In 17 conscftitivo cases of diabetic coma the
wtitet found them always present When ,i
small amount of a dense yello\vish-\\ Into deposit
appears exactly at the bottom of the mine
glass, and \vhoii this deposit consists of casts,
he believes that coma nearly always follows.
The casts m diabetic coma am finely granular
or hyaline, and arc piesent in enormous
numbers The urine in diabetic coma usually
gives a dark brownish -led coloiation with
perchloride of iron (Geihatdt's tcaction)
Acetone can also be detected The amount of
ammonia is much increased, and accotding to
Stadclmami/i-oxybutyiicacid is always piesent
The alkalinity of the blood is said to be much
decreased The blood always decoloiiscs an
alkaline mcth^leno blue solution as ahcady
dcsciibcd The knee-jetks aie usually absent
(absent in 20 out of 23 cases)
The coma often becomes complete , in other
cases the patient, though semi-comatose, can be
loused almost up to the List When once \\cll-
maiked symptoms of coma have developed,
death occms within forty-eight houis
The descnption just gi\en is that of the
common form of diabetic coma (Kussmaul's
vanoty), but theie aic two tate sub-\ ai ictics
(1) The al(vholt(, Joim At the onset the
patient i& veiy excited, and behaves like a
duinkcn man The pulse is quick, coma
develops, and soon tei mi nates fatal!} Such
cases have been mistaken foi alcoholic intoxica-
tion The mine gives the teaction with pc-r-
chlonde of iron, the bieath has tin1 "acetone"
smell, but dyspnoja is absent 01 slight (2)
Dinlxtic collaji\t (desciibed bj Diesihfeld and
Fienchs) The patient suddenly becomes
diowsy, the extremities and face cold and livid,
the pulse quick and small, and coma develops
The tempctature sinks subliminal, the hi oath
has not the "acetone ' smell, and the mine
does not contain acetone 01 duuctic acid
Dremhfclcl points out that tins foim <>f coma
oceuis cluc'iiy in patients ovei 10, and often
they ate well nomished 01 stout Diesdifeld
and Fi 01 u ha believe that the symptoms aie
due to cardiac failuie owing to degeneiation of
the cat due muscle
The Utftr/nvbii of diahutu coma (in its common
foim) is easy, especially if the patient is known
to h.ive been buffeting fiom diabetes foi some
time If the patient be seen foi the hist tirno
in the comatose state, then the diagnosis
between diabetic coma and othei foims of coma
has to be consideted li the mine can bo
I obtained, the ptesenco of a large quantity of
sugar, along with a high specific giavity, is
suthucnt to exclude most of the other causes
of coma The " acetone " smell of the bieath,
the pctchloTide of iron reaction in the mine,
and the dyspnoea aio also important indications
m favour of diabetic coma If the urine cannot
be obtained, or if there should be any doubt as
to the natuie of the case, the meth} lene blue
leaction obtained by examination of a diop of
the patient's blood will definitely settle the
diagnosis
In coma from fractured skull and other
DIABETES MELLITUS
331
ceicbral conditions occasionally the urine con-
tains sugar, but the quantity is only 8rn«ill, the
specific gravity is not high, tlu'ie is no pei-
chloridc of lion icdction, there is no "acetone"
smell of the In cut h and the mine, the pctuhai
dyspnea is absent, and the pulse is often slow
or normal , \\hilst in diabetic coma of the usual
iorui the pulse is rapid, and dyspnaa is a
piomment symptom Symptoms icscmbling
those of Kussmaul's diabetic coma aie stud to
oceui occasionally in other affections (cancel of
the stomach, anamiu, kidney disease), but in
such cases (as "vxell as in the alcoholic and
taidiac forms of diabetic coma) the diagnosis
can be made by the uiinc examination or by the
methyk'iic blue i ruction of a diop of the blood
The jMttholoifHiil rhanf/f* met xxith in patients
dying of diabetic coma aic not chaiacteiistic
The most constant aic those in the lenal
e])ithehuni already mentioned In the \aucty
of coma desciibed as diabetic collapse, it is xeiy
piob.ible that the cause is caidiac failure oxxing
to degeneiation oi the heart muscle1 In the
common vaiiety of diabetic coma, fat embolism
has been suggested as a cause in ceitam cases
Aecoiding to Submit/, the symptoms aic due
to a ptomaine ioimtd in the intestine o\\mg to
obstinate constipation The symptoms c eitamlx
j»omt to the action of some to\ic substance
Acetone and diaeetie acid have been suggested
.is the poison, but both substances (an be gi\en
in laigc doses xxithout producing coma (Diescb-
tcld ami othei s) Theie is ronsiuVi able ex idem «
in fax om of intoxication by some OIIMIHC acid
(Sladulm.inn), and /:?-ox}butxiu acidoi ciotonu
acid aie thought by some to bo the toxic sub-
stances \s ahcadx pointed out, the mine
neaily al xxaxs contains casts and a small
quantity of albumen m diabetic coma, and the
lenal epithelium fiequcntl} piesents diireueia-
ti\e change's Hence it appeus piobablo that
tlieie is nn pan me. nt of the lenal i unctions
V ILuley has shoxxu that symptoms lesemblmg
di.ibelic coma can be pioduced in animals by
injecting giapc-sugai into the jugulai \cm and
piexentiug its elimination by hgatuiing the
meteis Noxx in diabetic coma the su«rai
elimination and mine secietion usually dimmish,
<md tiom a considciatum of facts mentioned it
appeals not impiobahlc that coma is due to
poisoning oxung to the kidneys failing to
eliminate ceitam substances produced in the
diabetic oigamsrn
FCMXIS OK DlAHF/IES \ND GLVfOSUUlA TllCIO
«ire txxo chief foims besides several sub-xaneties
In the nvrie foim the sugai excietiou is gieut
and does not cease x\hen caibohydiates aio
excluded fiom the diet Thcic is often much
xxasting This inim is most common in patients
undci middle age In ehildien and }oung
pei sons it sometimes inns a A cry rapid course
(a few months or ex en less) In the mild foims
of diabetes the symptoms and sugar excretion
are not so marked The sugai disappeais iiom
the urine on withdrawing the caihoh^diateti
fiom the food The patients are often alwxo
middle age, and they are not infrequently stout
01 goutx The night urine contains less sugai
than the day mine, 01 it may be fiee fiorn
sugai The < omse is often chronic (This ioim
is sometimes spoken ot a& chionic gl}cosima)
There aie aKo tt(in\ition/tl and inteinifduiti
v.ineties, and the mild form may pass into the
sexeie In some of the mildest foims thnst,
dimesis, and othei symptoms aie absent, and
the onl} signs of disease uc in ide out bx
examination of the mine, \xhuh contains
sugai and has a high specific giavity (thabitf*
dtcijnnn) In auothei mild i< im the glycosuna
and other symptoms disappeai Fiom time to time
(intu inittdit diabetes) It has aheacly been
pointed out that glycosui'i maj b«- *c.c«nidaiy
I to a nuinbei of .iflections (\yiHjitmimtu glyco-
smia--w'<? aiticlc "(Jlxcosmia") Hanot,
(/hautlaid, and othcis haxe diaxxn attention
to a iaie chsc'aso chaiai tensc-d by the associa-
tion of symptoms ot diabete^ inelbtus \vith
bion/c'd ])igmentation of the skin, and fie(|uently
xxith hjpeitiophio cnihosis of tlie hxc-i (fluififte
It on (')
TjiimiNAiioN — The sexeie foims alxx.ijs tei-
nimatc fatally The duiati'in mav bf a few
jcais(3-3); oftc'ii it is shoitei , occasionally it
is A fex\ months, 01 ex en less In the mild
casts life liny be pioloiured foi man} }ears
(10 01 JO) In the mild ca^es bx if»»tnctiil or
ngid diet the sxmptoms ma} dis.ippt.ai entnely,
tmt thc>} usuallx letuin xxlun an oidin.uy diet
is taken
In iaie cases diahetts is associated xxith
sxmptoms of nephiitis (paunclnmatous 01
mteistiti.il), and the diabetic sunptoms ma\
giaduallx subxido xxhilst tho'-e of nephiitis
leinam Also cu c asion illx (tlicmuh vei} laicl})
the sxmptoms of diabetes mellitus give place
to those of diabetes msipidus
The fatal toimiiiation in diab»»tes mellitus is
mo^t fiequently bx diabetic com.i The next
most frcqucMit tcinnnation is by pulmonaiy
phthisis Othei causes of death aie cMibuncle,
ganmene, etc
Tiih 1'iMMiNohis depends chiefl} on the Ioim
of the disease .mil the age of the pitient In
the mild foims, especial h if the1 sugai excietion
can be checked by a iigid diet, and it the
]wtient be ovei middle age, the piognosis is
fanly fax oui ablo Hut it is vciy giaxe in
}oung pei sons md in the sexeie loims of the
disease Othei nnfavoiiialilc indications are
maikcd xxasting, the occmience of pulmonary
tubeuulosis, a family history of the disease,
unfa\omable conditions of life, Woihault's per-
chloiide of lion leaction in the mine, signs of
commencing coma, onsc»t of gangi ene
Faromallc nuhuttiojn m addition to those
already mentioned arc the association of obesity
332
DIABETES MELLITUS
or gout, loiig duration of the disease without
much wasting, favourable conditions of life, in
the female onset about the climacteric period.
THE DIAGNOSIS of diabetes mollitus is usually
easy. The disease may be overlooked, howevet,
and the patient treated simply for one of the
complications It is impoitant to reiucnibci
that occasionally the patient complains chiefly
of weakness and casting It is impoitant not
to mistake a tempoi.uy and mild gljtosuna foi
true diabetes
PATHOTOOIf'AL VXAfOV\ — NlllHClOUS patho-
logical changes have boon desmbed in di.ibotes,
yet, strict!} speaking, the disease has no definite
pathological anatomy The changes met with
are usually duo to complications or arc secondary
in natuie, and it would scaicely be possible for
a pathologist to diagnose diabetes without a
clinical histoiy 01 the chemical examination of
the mine or blood For this leason the changes
found post-mortem m the various organs have
been already dcsciibed in consideiing the relation
of diabetes to disease of the ncivous system,
liver, and pancieas, and m the description of
the complications The condition of the blood
has been described under the symptomatology
PATHCM.EVEMS — The true natuie of the
disease icmams oWuie The thconos as to
its exact origin aic nuineious, but none is
altogether satisfactoiy Sugar appeals in the
urine because theie is an excess of sugai in the
blood, and the symptoms of the disease are due
to the same caus»e
The cause of the excess of sugai in the blood
has been attributed to (1) an excessive formation
of sugar in the system , (2) a diminished sugai
destiuction, (3) by some wnteis it is bchcxed
that in certain cases there is an excessive
sugar formation, in othein a diminished sugar
destruction Bunge has given good reasons foi
rejecting the Mew of exce*sive formation as
regards the origin of the sugar from aiticles
of food Kaufmann, on the other hand, has
brought forwaid expenmental oudeuce in favour
of increased siii^ai foimution He isolated the
liver by tvmg all its vessels m a healthy
dog, and also in another dog which had been
rendered diabetic by extirpation of the pun-
creas The sugar m the blood gradually
became diminished dm ing its en dilation m
various parts of the body, but the blood lost
the same proportion of sugar both in the
healthy and m the diabetic animal Hence,
he concludes that sugar destruction was the
same in each
Many authors believe that diabetes m man
is usually due to diminished sugai destruction
In the mild forms of diabetes removal of carbo-
hydiates froni the diet causes the glycosuna to
cease In such cases the sugar appears to be
derived in some way, directly or indirectly, from
the carbohydiates of the food Scegen believes
that in the mild form (which he terms the
"hepatogenic") the liver cells are unable to
assimilate the caibohydratos in a normal
manner But pathological anatomy has failed
to reveal any definite changes in the liver
associated with diabetes.
According to Pavy, the two lines of defence —
intestinal ulh and the liver— aic inadequate to
accomplish the function of synthcsismg the
caibohydrate-s Hence the lattei leach the
geneiul ciiculation in excessive quantity and
appeal as sugar in the urine
In the wwr fonm of dtahete* the sugai in
the urine is evidently not dependent simply
on the caiboh)diates of the food Since the
glycosuna pcisists when the diet consists only
of fat and nitrogenous substances, and persists
evon when no food is taken, Pavy believes that
in these severe foims the sugar is dcnvcd not
only from the foxxl but also from the tissues
Ho'bclic'vcs tint the pioteids of the body ha\e
a glucoside constitution, and that in diabetes
of the seveie foi in a caibohvdiatc is cloaved
oft fiom these proteids by the action of some
feimcnt which ho supposes to be piescnt in
the system
Accoiding to Socgen, in the severe foims the
< ells and tissues of the organisms have lost then
function of destioymtj the sugar in the blood
Limited space forbids a discussion oi the
subject, but whatever view we take of the
sugar foimation or destruction the question
finally anscs, What is the came of the abnor-
mality m dialjetei* *
Pavy believes that as legaids the liver theie
m a \asomotor paialysis and dilatation ot the
small aitenoles owing to some change in tho
nervous system As a icsult the blood in the
liver is in a h v per-oxygenated state, 'and this
favours the passage of cai bohydrates into
glucose But Seegcu points out that Pavy was
able to puiduce diabetes experimentally by
injury to the neivous system aftei ligature of
the hepatic aiteiv, and he asks, therefore, how
vasomotor parahsis can be rcgaided as the
explanation
It has been aheady shown that there is
stiong evidence that some change in the nervous
system is the stai ting -point of the disease in
many cases
Also expcnmcntH on animals and pathological
observations lender it very probable that, in
some cases of diabetes, pancreatic changes aie
the cause of the disease
It has also been pointed out that atheioma
might act as the starting-point of diabetes by
producing changes m the nervous system or in
the pancreas, and there aie a few cases on
record which afford strong evidence of diabetes
being the result of pancreatic changes which
were secondary to atheioma
Diabetes has been attributed by Bungo and
others to pathological chemical changes com-
mencing m the muscles.
DIABETES MELLITUS
333
The opinion appears to bo gradually gaining
ground that diabetes IB not a pathological
entity, but rather a group of symptoms which
may be produced by the various morbid changes
aheady suggested. Possibly it is sometimes
due to an endogenous or inherited morbid con-
dition, and possibly to other causes.
TREATMENT
The results of treatment in the mild forms
aie good, in the severe forms very unsatisfactory
After a diagnosis has been made, before com-
mencing treatment, the weight should lx) taken,
complications noted, the amount of sugar esti-
mated, and the mine tested with perchloride of
iron Then a ngid diet (practically fice from
caibohydrates) should be piescnbed in order to
ascertain \\hcthei the sugai excretion can be
checked thereby If this should occur the case
belongs to the mild foim of the disease, and a
little carl xjhydi ate food in the foim of bicad is
then allowed and gradually increased (if ncccs-
saiy) until the glycosuna rctuius The amount
oi bread which can be taken before the lotuin
of the glycosmia is thus an indication of the
quantity of caibohydiate food the patient can
tolerate If a diet tree fiom c'libohydiates does
not cause the sugai todisappeai fiom the mine,
then the patient is suffering fiom a severe foim
of the disease If theic should be great wasting,
and especially il the in mo should give a marked
reaction with peichlonde of 11011, it is not ad\is-
able to keep the patient long on this very iigid
diet
Many authois think it is important m the xery
severe foims of the disease th.it the rigid test
diet should not be commenced suddenly, as bj
such a proceduie theic is a possibility of pro-
ducing diabetic coma (Ebstem, Naunyn, and
otheis) A few days may be allowed to elapse
in changing from a mixed to a iigid diet Pota-
toes may be excluded fiist, then bread, and
aftei wards all other carboh \diates This plan
appeals to the witter to be impoitaut
Having determined the effect of diet and the
form of the disease in any case, directions must
be given foi the future DIETETIC TUBAIMENT — (1)
as to the natm e of the food, (2) as to its quantity
The treatment must be modified m each case
according to the form of the disease A recoid
of the weight and sugai excretion should be
kept, and piobably the former is the more im-
portant
IN THE Mi hi) FORMS OF THE DISEASE theic
are two classes of cases (1) those in which the
sugar exciotion ceases only when caibohydrates
are excluded from the diet , (2) those in \vhich
it ceases when the carbohydrates food is simply
diminished m quantity In either case the diet
which is sufficient to arrest the glycosuna should
be continued for several weeks. It is often
found that the condition of the patient is then
much improved. In the first class of cases he is
able to take a little caibohydrate , m the second
class he is able to take an increased amount of
carbohydrate without the glycosuna recurring
But in many of the first class of cases any
addition of caibohydiatcs to the diet is followed
by a return of the glycosuna After a period of
restziction, however, it is usually necessary to
relax the diet a little, Specially as regards
bicad, and to remain content if by a moderately
restricted diet \ve can limit the sugar excietion
to 500 or 600 grains daily If the patient
should be very stout a reduction of the total
quantity of food is often of gieat scivice, but if
wasted this should not be attempted.
IN THE, SEVERE FORMS op THK DISEASE, when
the most rigid diet fails to leruove sugar from
the mine, and when theic is much wasting, and
especially if the urine give a marked reaction
with pcnhloudo of iiou, the opinion has been
giadually gaining ground ior some yeais that a
xery iigid diet is injiiiiou* In such cases, after
a shoit penod of rigid dietaiy (in oidei to
dcteimme the form of the disease), a small
amount of carbohxdiate food must be allowed
The diet m these soveie forms should consist of
nitrogenous food, f.itty food, and a small amount
of caibohydiate food, chiefly in the form of
biead , but saccharine food should be avoided,
and the carbohydiate food should only bo
allowed in limited quantity Fatty food is
especially impoitaut, and should be given in
laii>c quantities, a little alcohol being also
alloued to aid its digestion Cieam is of gieat
sci \ ice, and should be gixen freely, also milk
may be allowed in model ate quantities If coma
appcam to be thicatcumg the diet should be less
ngid, i e the amount of caibohydiate should be
uici cased According to Ebstcm, the appearance
of acetone and diacctic acid m the urine is an
indication foi diminishing the albumen and for
mci easing the carbohydrates
ARTICLES 01 DIKI When a rigid diet is
indicated (cither foi diagnosis or foi treatment),
the following aiticlcs should be sanctioned or
forbidden —
tiaii (firmed
Butchers' meat of all
kinds (except liver),
potted and pieser\cd
meats
Ham, tongue, bacon
Poultry, game !
Fish (fresh, dried, and ,
pieservcd), sardines, ,
shrimps
Broths, animal soups,
and jellies (piepaied
without the addi-
tion of saccharine 01
starch materials)
Eggs, cheese, cream i
Fnrbultlen
Sugar, sacchaime and
farinaceous articles
of food
Pastiy and farinaceous
puddings
llice, sago, arrowroot,
tapioca,' macaioiu,
vei mu elli, semolina
Potatoes.
334
DIABETES MELLITUS
Sanctioned , Foi bidden
Butter, suet, oilo, and1
fats
Custaid (w ithout sugai ) ,
Reliable bicad substi-i Wheatcn biead
tutes (gluten bic«id,| biscuits
almond and tileiiioii.it,
cakes)
and
Uieen M?getables —
C aiiots, tin nips, pai-
mustaid <uid uess,
snips, bccti oot, beans,
watei ci ess, endn e,
peas, laige onions
lettuce, spinach,
turnip-tops, t abbage,
bioccoh, Biussels
sprouts, spi mu; onions
Cucunibtn
Livei
Mushiooms
O^steis, cockles, mus-
sels, the " puddings"
of ciabs and lobstcis
Pickles (cm umhci, wal-
lloncy
nuts, and nmons)
Nuts (walnuts, almonds,
All sweet fiuit And
filhcits, ha/el nuts,
dued hints
Bia/il nuts), but not
chestnuts.
Hl'M3HA(,ES
WuU'i, s<xla-watoi, .aid Poit, Tokay, th.uu-
nuncial \iateis pagnu, and sweet
Tea, coffee ' cities
Di\ sheii \,<laict, Mm- ) Must, fiuit juices and
gundy, lux k, Moselle, I syiups
Ahi
most
lihino w inch, Austi lan
and Hung.man table
wines (all in model -
ate quantities how-
ever)
Biandy in small quanti-
ties
Sweet lemonade
Liqucuis
lieei, ale, poitei, and
stout
Ruin and sw cetcned gin
Cocoa and < hocolatc
Milk in laige quantities
Almost all kinds of animal food may be
sanctioned, but liver, oysters, cockles, mussels,
crabs, and lobsteis should bo avoided, because
they contain a Luge amount of caibohydrate
matenal
Withiegatd to mi Ik caution is nccessaiy, since
it contains 4 per cent of milk-sugar, but it also
contains albuminous bodies and fat, \ilnch aie
of great seivicc to the diabetic In some cases
the addition of milk in considerable quantity to
the diet of a diabetic patient docs not increase
the sugar excretion, le the milk-sugar is
utilised m the system In other cases the
glycoBiiria is distinctly increased by the milk,
but nevertheless such patients may gam weight
hi the very sevcie forms of the disease milk is
of great service, especially if the digestion is
feeble, but ih milder forms, if a rigid diet be
desirable, milk should be excluded, unless it can
be shown that it does not increase the glycosuna
Cream contains less lactose than milk, but
seven times the amount of fat. It may bo taken
freely by diabetic patients, and is most useful in
the severe founs of the disease By the follow-
ing simple method an artificial milk can bo
prcpaied from cream — To about a pint of water
placed in a pot or glass measure font tahlespoon-
fuls of fiesh cieam are added and \\ell mixed
The mixture is allowed to stand foi twelve
hours Most of the fatty matter of the cream
floats to the top, and can be skimmed off >uth
a teaspoon, and on examination it will be found
almost free fioui sugai (the sugar originally
piesent in the cieam having been dissolved and
distuhutcd in the water) This fatty mattei is
then separated and placed in a glass and mixed
with water The white of an egg is added, and
the mixtuie well stnrcd A little salt and a
tiace of sacehaimc may be added The mivtuie
with a little piactice may be made to taste
almost like milk, and it may be taken fieely bj
all diabetic patients
Fat\ are the most valuable ai titles of diet foi
diabetu patients, especially in the severe foi ms
of the disease, and may be allowed in Luge
quantities The most useful are buttei, ucam,
bacon, cheese, eggs, suet Tod-livci oil is also
of seivue li fatty lood should gi\e use to
dyspepsia, a small amount ot biandy and watei,
01 other foi in of alcohol, taken aftci the meal,
often aids the digestion
Of the (aihnhyiliate*, staich is less mjuiious
than sugfU Of the various kinds of sugai,
glucose is most injurious Milk-sugu andcaue-
sugai lank next Lduvulose is least injurious
Many obsen ahons have shown that in moderate
quantities Levulose is utilised in the system, and
does not mcicasc the sugai exaction in mild
forms ot diabetes , but in laige quantities, and
in the severe foims of the disease, it is onlv
partially utilised, and thcirfoie the sugar excie-
tion is mi i eased Saccharine and s.v\imv may be
used to sweeten aiticles of food in place of sugai
When a \eiy rigid diet IN indicated ftuit
should be excluded, on account of the sugai
which it contains But m many kinds of fiuit
a laige portion of the sugar is Lmulose, which,
as jiwt mentioned, can be utilised in small
quantities m certain cases Hence when a veiy
iigid diet is not necessary, a veiy small quantity
of those fruits u hu h contain least sugar may be
allowed.
Giapes, cherries, and other fruits which con-
tain much sugai, as well as dates, figs, currants,
raisins, and other dued fruit, should be forbidden
Nuts may be allowed freely, w ith the exception
of chestnuts As a rule green vegetables may
be allowed, whilst white vegetables and root
vegetables, which contain more carbohydrate,
should be avoided These have been already
indicated
Bread is the article of diet with respect to
which there is the greatest difficulty It con-
tains 49 per cent of carbohydrates and 2 per
cent of sugar (Konig), and is thus unsuitable
DIABETES MELL1TUS
335
when a ^el y rigid diet is dosnablo for diagnosis
or treatment In such cases it must be replaced
by various bread substitutes Unfortunately
many of these <iie veiy unreliable, and contain
either staich or sugar in considerable quantity
Bcfoie recommending any specimen it is imiK)i t-
ant to tiy the effect of a drop of iodine and
potassium iodide solution If the specimen
becomes deep blue black it contains a laige
quantity of starch .aid is unreliable Some
bread substitutes contain sugar, and hence it is
adusable to test foi sugar by the fei mentation
test in an mveited test-tube
In the most scveie foims of the disease, when
a MJiy ngid diet is not desirable, it is best to
allow a small amount of oidmaiy bread daily ,
in othei rases when foi diagnosis 01 treatment a
veiy iigid diet is ncccssaiy, bread should bo
excluded fiom the diet foi a few weeks, and
some tellable substitute employed But aftei a
month 01 t\\o most patients find bread substi-
tutes objectionable, and it is ncccssaiy and often
desu.ible to allo\v a small quantity of ordinal}
biead The following hiead substitutes have
been emplo>ed -
(i ) (ilnttn ft t mi*/ — (iood piepaiations of
gluten floui .tie almost unaffected by iodine, and
contain onl\ 12 to .'5 pel centof cailiohydiate The
flour can be pm< based and the bieid piepared
at the patient's house ac< oidmg tothedneetions
supplied b} \,uious mms With eaie .1 fauly
palatable and leh.ible ]>ie])ai.ition ma^ be ob-
tained which \\ill be of seiMie as a In cad substi-
tute, and \\ill e.iuse «v i eduction of the sugai
excietion Hut mam piepaiations aio veiy
unpalatable «ind unichahle (n ) Jixtn cale w.is
recommended bj Camplin many }eais ago, but
is now seldom used (in ) tfoi/a biwuit and
biead ha\e been laigely used leccntly They
are piepared fiom soya l>eans, and some speei-
mens contain only a small peicentago of staich
(3 to fi), but othei. s contain as much as 30 01 45,
and aie then-fore useless (iv ) Almond c<dd
weic leiommended by 1'avv long ago They
tan be piepaied at the patient's home fiom
almond floui About 4 ounces of almond floui
aie mixed into a paste with a little water and
German jeast The mixture is allowed to stand
in a \\aim place foi about t \\enty minutes
Then one egg, beaten up, and a little cre«un and
watei aie added, and the whole is mixed into a
paste, di\ ided into cakes, and baked for fifteen
to thut\ minutes (v ) (Jwoa-nut cakes may be
prepaied in the same way by using desiccated
cocoa-nut powdei in place of almond flour
Both almond floui and cocoa-nut powder contain
a small amount of sugai, which is destroyed by
the action of the yeast used in making the
cakes. Both of these cakes contain a large
amount of fat, and hence a little alcohol is often
necessary to aid their digestion Almond flour
and cocoa-nut powder may be used for the
preparation of pudding
(vi ) Aleuronat is a \cgetable albuminous
substance winch contains only a \eiy small
percentage of carbohydrate, and winch has been
stiongly recommended by Ebstem The \\ntei
has found that palatable and reliable biscuits
can be picpared by mixing aleuronat and cocoa-
nut po\\dei
Two ounces of desiccated cocoa-nut powdei
are mixed with a little water and (Jeiman yeast,
so as to form a paste This is kept in a warm
place foi half an houi, then 2 ounces of aleuionat,
one egg (beaten up), and a small quantity of
water, with a little saceharme, are added The
whole is mixed into a paste, which is spread out
on a tin, dmded into cakes, and baked for
twenty or Unity minutes
Tin UMEKUJFS whieh aie fiee, or almost free,
horn ( ai boh \ drates m i\ be allowed, and they
have been aheady indicated Alcohol does not
mcieaso the sugai excietion, and theiefoie
alcoholic drinks which contain only a ^ely
small quantity of caibohuliate may be allowed
in moderation In the se\eie foi nib of the
disease, alcohol is of seivice in enabling the
patient to take laige quantities of fatty food
without d \speptie tumbles
The follow ing is a useful lemonade foi the
lehef of thnst — eitiic acid 10 giams, glyceime
1 drachms, watei 1 pint , thin may be taken
in small quantities during the twenty -foui
houis , 01 a lemonade m.i) be made fiom fiesh
lemons and sweetened with sacchaiine Othei
acid dunks may be used The laigest quantity
of fluid should be taken befoie, not tiftei, a
meal
THE Mont or LHP AND (»EMJIAI IhuiEvic
CONDTIIOXS — It is nnpoitant to iehe\e the
patient fiom mental woiry and anxiety as much
as possible Consideiablc muscular exercise in
the open an ih of gie.it service in some of the
mildei eases, and sometimes causes a diminution
of the glycosuna, but in the sevcie foims it is
injuiious Massage is of seiMcc in some cases
(accoiding to Ciuhe in those associated with
ciitciio-scleiosis)
TREATMENT u\ ALKILINK MI&KUAI WATERS —
The spas of Cailsbad, Marienbad, Neuenahi,
iii id Vichy aie much fiequented b) diabetic
patients on account of the supposed \ntiicsof
then mmeial watei s» The salts in the wateis
of (Uilsbad and Manenbad consist chiefly of
sodium sulphate and sodium bicarbonate , those
in the waters of Ncuenahr and Vichy chiefly of
sodium bicaibonate It is useless and often
dangerous to send English patients suffering
from the wvoe forms of diabetes to these spas
The long journey has not infrequently acted as
an exciting cause of diabetic coma Arterio-
sclerosis is stated by Schnutz to 'be a contra-
indication of the Neuenahr waters It is
certain, however, that patients suffeiing from
the mild forms of the disease (chiefly those
which are associated with obesity or gout) do
336
DIABETES MELLITUS
often derive much benefit fiom a visit to these
spas. !But whether the results are due to the
action of the watora or to the improved general
conditions of life, more careful diet, and life in
the open air, IK a disputed point. (But fiom
limited observations at Carlsbad and Neuenahr,
the writer is inclined to attribute part of the
good results obtained in the mild cases to the
action of the waters )
MEDICAL TREATMENT — It is certain that no
drug hitherto tiiod has a definite curative
action, but several have a beneficial effect
Opium and ifa alkaloid* have been long em-
ployed, and aro probably moio usetul than
othei drags At first half a gram of opium
may be given three times a day The dose
may bo giadually increased to 2 or 3 or more
grains of opium three times a day, as diabetic
patients aro very toleiant of the drug Ralfe
advised it to bo given an hour after a meal,
since at this time ho believed it had a greater
effect in restraining dimes is, and was less liable
to cause dyspeptic symptoms Some authors
prefer the ciude opium, others morphia, and
others codeia Thf» last drug has been specially
recommended by Pavy It may be given in
small doses at first, half a gram thiee times a
day, and giadually increased to 2 or 3 grams
All the opium preparations aio liable to cause
tioublesomc constipation and dyspeptic symp-
toms, and therefore icquire watching, but
probably codeia is less injurious in this respect
Next to opium and its alkaloid, alkalies have
been, perhaps, most frequently employed in the
treatment of diabetes The alkalies which aie
most often used are the bicarbonate of soda,
and the citrate, a< otate, carbonate or bicarbonate
of potash
Nauuyn stioni;ly advocates the use of sodium
bicarbonate in Lugo doses in severe canes of
diabetes befoie the onset of symptoms of coma,
and when there aie indications of acid intoxica-
tion, such as great excretion of ammonia or
marked reaction of the urine with porchloiido
of iron So long us the pel chloride of iron
reaction is intense, ho advises that bicaibonato
of soda (150 to 450 plains daily) should be
given, and that it should be increased m amount
if the poi chloride leaution inci eases. Since
adopting this tieatment (twelve years ago) the
numlxjr of cases of coma in his practice has
diminished greatly
Lithium salts (carbonate and citrate) have
been much employed (often combined with
arsenic). In cases associated with gout they
may bo of service
Arsenic has been much prescribed m the
treatment of diabetes, and m some of the milder
cases it probably is of some service, when the
dose is gradually increased (up to 10 m of the
liquor arsemcalis three times a day)
Jambid has been often prescribed in diabetes
during recent years Many observers have
found it useless , others have obtained favourable
results when the drug has been given in suffi-
ciently largo doses.
Sodium sahcytate has been recommended by
Ebstem, who piescribes it freely Brunton and
Balfc think it is of most service in the gly-
cosuria of gouty persons Schmitz of Nmenahr
obtained better results with salicylate of bismuth
than with any other drug in the mild forms of
the disease (7J grains twice a day)
Recently -uranium nitrate has been recom-
mended by West, and there is certainly some
evidence in its favour
Numerous other drugs have been recom-
mended from tune to time, but usually extended
experience has shown them to be useless or of
very slight value
Cod-hvei oil 01 lipanin aie to be ictoi amended
when the patient is much wasted
TREATMENT OP COMPLICATIONS — When nuta-
tion ,iud eczema of the genital oigans (vulva or
piepuce) is a tioublcsome symptom, it is im-
poitant that the external orifice of the uiothia
and sunouiiding parts should be diied with hut
01 absorbent cotton-wool diiectly aftci each act
of micturition Boracic acid ointment, boracic
acid lotion, or a solution of sodium hj posulphite
(one m foity) may be applied The treatment
of othei complications — boils, carbuncles, i*an-
giene, phthisis, nephritis, etc — is described
elsewhere in the ai tides devoted to those
subjects
PREVENTION AND TIIKAIMFNI' op DIABEHC
COMA — In the severe foims ot diabetes, when
theio is much wasting or when the urine gives
a marked reaction with peichlonde of 11011,
thei e is great dangct ot coma developing In
such cases it is impoitant to lemember that a
long railway journey, over-e\oition, 01 sudden
change of diet u* liable to be followed by coma
Prolonged constipation is also dangoious As
already mentioned, the diet ought not to be
too rigid Some carbohydiato food (especially
bread) ought to be allowed Cicam and fatty
food should be given fiooly Whencvci theio
are signs of commencing coma, the oaibohydratcs
in the diet should be increased a little and the
nitrogenous food diminished Constipation
should be relieved by the use of puigativos,
and Schmitz behoves that ho has checked the
onset of coma by producing free action of the
bowels with castor oil
In severe cases, especially when the pcr-
chlonde of iron reaction IH intense, alkalies
should be given in largo quantities — 400 to 500
grains of sodium bicarbonate in the twenty-four
hours Naunyn behoves that this treatment is
of great importance, and that the onset of coma
may sometimes be prevented thereby for a long
period. When early symptoms of coma are
observed alkaline treatment ought to be com-
menced at once, if it has not been prescribed
previously A number of cases aro now on
DIABETES MKLLITUS
337
record in which the early symptoms of coma
have subsided under vigorous alkaline treat-
in out
Sodium bicaibonate may be given in a little
milk or in an effeivcHCing draught with a littles
citric acid and sacchaime (Yeo), 01 citrate of
sodium may bo given (900 grains in the twenty-
foui houis, Lcpinc)
Dining tho last ten ycais the mtia\cnous or
subcutaneous injections oi warm alkaline 01 h<ilt
solutions, as recommended by Stadclmann, lune
often been tiled when coma h.is become well
maiked Tlieie can be no doubt (I) that tins
method of treatment has often «i decidedly
beneficial effect, but (2) that the icsults aie
usually only teuipoiaiy, and a fatal termination
is very raiely prevented
Solutions \vhu-h have been (hielly used aie
A 3 to 5 pei cent solution of sodium bicarbonate
in 0 6 to 0 7 pet cent sodium c blonde solution,
a 3 pei cent watery solution of sodium bicai-
bonate, a solution of 10 giammes oi sodium
bicaibonate and 7 grammes of sodium chlonde
in a litie of sterilised water (Lepme), a 0 6 pei
cent solution of sodium chlonde (v Nooiden)
Intravenous injection (into the median basilic
\em) is to be preiened to subcutaneous injec-
tion It is impoitant that the fluid should be
\varm (Lepine lecommends a tcmpeiature of
38° C =100 4J F ) A Luge quantity of fluid
should be used (2\ pints Oh\ei, 2 hties Lepinc)
Usually the onfy lesult is an nnpro\ ement in
the ])ulsc and a diminution of the coldness ot
the skin and a little diminution of the coma, so
that the patient can be moic easily loused
But octdMonally the coma disappeais paitmllv
or completely, so that the patient can convcise
with his fi lends , usually a i elapse soon occms
Diacetic Acid. - Diacetic acid (C1I<
CO Cllj COOH) oi aceto-acetu acid is sometimes
found m the mine in diabetes (it is piobably
nevei present in health) , \vith a solution of
ihlondc of lion it gixesa Boideaux 01 Buigundy
led coloui, but not if the mine has been pie-
viously Ixnlcd and allowed to tool (p 320), it
bicaks up quickly into acetone and taiboinc
acid tite DIABKJ-ES MKLUIUS (Diabetic Coma} ,
UiiiNE, PAT nor ooK'AL CHAM. hs IN (Ac<.tom,Ai etu-
Aretic Acitt, etc )
Diacetliria. — The picscnce of di.icetic
acid in the mine , Geihaidt's looctum (tee p
320) Kee UNCoNsnousXEss (A utomtoxi cations)
Dlacety I morphine. See HEROIN
DiaChalaSma.— A fissure or cleft (fiom
Or SiaxaAaw, f loosen, and (Sia\aAooyia, a hiatus)
Diachylon. — Emplastium plmnbi or
lead olcatc, diachylon ointment is formed by
melting together equal parts of lead plaster and
soft parafhn, and mixing with an equal quantity
of 71 nc oleate ointment and mercuric oleate
ointment, diachylon pills have been used to
punoke aboition.
Diaderitt. — A blastcxlcun, in which there
aie two laycis or plates of cells, ectoderm and
entoderm, joined at then edge (ectental line),
<iud suiiounding a ccntial segmentation cavity
(Mnwjt) , tho eaihest fmm of the diadcim is
known as the Miittitla
. — The excretion of fteces
(from (»r Sta\t»pcti>t I pass tlnough)
DlaChriSlS. — An inunction (from Or
£tax/oui>, I anoint).
VOL. II
— Sepaiation 01 solution of
rontmuity In the classification of teiatology,
TaiuHi giouped the monochoi ionic twins, the
placental paiasites, and the united twins undci
the heading of the disom ita , to the mono-
choiioinc twins and placeutal paiasites he gave
the name ttunetic <h«jmata, for the bodies of
the two fuutuscs aie s» paiate, although theie
may be communication by means of the vessels
oi the umbilical coids, the united twins he
(•tilled st/ntrietic diwuiakt (Ballanfryne's Ante-
natal Patlwloyy, vol n p 6J3)
Diagnosis. — The pioccss of distinguish-
ing between different states, usually different
diseases , it implies a certain amount of difh-
< ulty, and when difhuilty is absent the process
is one rathei of iccogmtion th«ui of diagnosis
Symptoimttu diagnosis <lepcnds ui>on the con-
sidei«ition of syni}>toms alone, while physical
diagnosis is based on the physical signs which
miv be elicited by the medical man It is
almost tautological to speak of difftitntuU
diagnosis Diagnosis by enln^on is the piocess
by which the piesencc of c\eiy other possible
state has been shown by the conditions present
to be insufhcicntly established , the only othei
possibility that is left is then icgaidcd as the
state which is present *SV<- AHDOMEN, CLINICAL
I\\LSIIOA11ON OF , (hNECOLOdY, DIAGNOSIS IN,
Posr-MoHiEM MKTHOUS } etc , etc
Diagonal Conjugate. &e LABOUR,
Pli^sioiutT^ oi- (ffard yVts^f/c*, Diantetej*)
DialuriC Acid.- A monobasic acid
(<14H4\_,O4) obtained fiom allo\an (CVIjNjO,
+ 4! I/)) by the action of h^diogeu sulphide"
Dialysed Iron. — Liquoi Fein Dialy-
satus (Wi/eth) is a mild piepaiation of iron,
ie(ommended in the case of delicate children,
and given in doses of 5 to 30 m m watei
Dialysis. — The intcrdiftusion of two
liquids (one of which is geneially pure water)
separated irom each othei by an animal mein-
biane 01 paiLhment papei , the "portion of a
liquid which passes tlnough into the \vater is
called the rttfuvtte, and the poition left behind
is the <hah/\ate , (ry&talloids diffuse much more
quickly than colloids
3S8
DIAMETER
Diameter.— The distance from a point
in the periphery of a circle passing through the
centre to the corresponding point on the opposite
aide ; the same measurement made in the case
of a spherical, circular, or cylindrical body.
There are various pelvic diameters (such as the
conjugate, true, diagonal, and external), the
cranial diameters (such as the occipito-froiital,
occipito-mental, biparietal, etc.), and the cor-
poreal diameters (such as the bisacromial, the
sterno-vortebral, etc.).
DlamldO Adds. — Acids with two
amidogens (NH2) replacing two hydrogen atoms
in their molecule, such as lysin (diamido-caproic
acid) and diamido-propionic acid.
Dlamln
•Bases in which two atoms of
hydrogen in ammonia have been
radicals, e.g. ethylene-diamine (C2Ht(Nf
diethylene-diamine orpiperasine (NH(C?E ^
&0URIN?, PATHOLOGICAL CHANGES IN (Ab
Nitrogenous Constituents, Diamines).
Dlamlnurla.— The presence of diamines
(cadaverine, putrescino, etc.) in the urine. See
URINE, PATHOLOGICAL CHANGES IN (Abnormal
Nitrogenous Constituents, Diamines).
Dlapedesle.— The passage (during in-
flammation) of the red corpuscles of the blood
out of blood-vessels into the surrounding tissues;
they are supposed to pass through the un-
ruptured vessel walls either between the endo-
thelial cells or through openings made by. the
leucocytes, but it is more likely that they pass
out through the bursting of capillaries; the
process is to be distinguished from the emigra-
tion of leucocytes, occurring as a rule before the
latter has become active. See PHYSIOLOGY,
NUTRITION OP THE TISSUES, THE BLOOD (Cells of
the Blood) ; SUPPURATION (Acute Circumscribed
Abscess).
Diaper. — A napkin, worn to absorb dis-
charges from bladder, bowels, orj vagina;
sanitary towel.
Diaphoretics. See also PHARMACOLOGY;
PRESCRIBING; AMMONIUM; etc.— The term dia-
phoretics is applied to all measures which
increase the secretion of sweat.
The Physiology of Sweating.— The activity of
the sweat glands is closely related to the condi-
tion of the cutaneous circulation, and therefore
to the heat-regulating mechanism. When the
surrounding atmosphere is warm the cutaneous
vessels dilate, the amount of sweat is increased,
and heat is lost by the resulting evaporation.
When the atmosphere is cold the vessels of the
skin contract and the amount of sweat is de-
creased. The sweat glands are not> however,
actually dependent on the cutaneous circulation,
but their activity is under the influence of a
nervous mechanism analogous to that presiding
over other secreting organs. This fact is
supported not only by experimental evidence,
but by such evidence as the occurrence of
sweating from mental emotion, the sweating
brought about by a venous condition of tho
blood, or the reflex sweating which results from
the introduction of pungent substances into the
mouth.
Enumeration and Mode of Action. — The
principal diaphoretics are warmth; hot drinks;
jaborandi (pilocarpin) ; liquor ammonia) acetatis
or citratis ; potassii citraa ; potassii nitras ; ipe-
cacuanha (Dover's powder); opium; antimonium
(pulvis antimonialis or viiuim an time-male) ;
alcohol; saliciii and the salicylatos; various
pungent and aromatic substances.
Wo find the simplest means of producing
diaphoresis in tho direct application of heat to
the skin, whether by means of warm baths, of
hot air or vapour baths, or tho various kinds of
packs. The sweating appears to be brought
about not by direct stimulation of the sudori-
ferous glands, but through the action of the
central nervous system. It may be greatly
aided by the administration of hot drinks*
possibly owing to an increased flow of warm
blood through tho nerve centres; and these,
further, may bo stimulated refloxly by the
addition to the drinks of pungent or upicy
substances. Alcohol produces diaphoresis chiefly
by dilating the cutaneous vessels and increas-
ing the circulation through the skin, but it
also stimulates the nervous mechanism. Likiv
other narcotics, such as opium, it produces
sweating hi the later stages of its action by
increasing the venosity of the blood. Pilocarpin
produces copious sweating chiefly by stimulat-
ing the peripheral ends of the secretory nerves,
while nicotine produces a similar result chiefly
by acting on the central nervous system.
Uses.— -Diaphoretic measures are largely used
on account of their antipyretic effect in pyrexia
associated with the onset of acute specific fevers^
or tho occurrence of acute local inflammations..
For example, at the onset of an attack of acute-
nasal or bronchial catarrh the administration at
bedtime of a small dose of opium combined with
other diaphoretics will often be found to greatly
relieve both the local and the general discomfort.
A quarter of a grain of morphia may be ordered
in a glass of hot toddy, or from 5 to 10 grains
each of Dover's powder and phenacetin. This,
should be followed on the next day by the
administration of such diaphoretics as liquor
ammonia acetatis and spiritus »theris nitrosi ;
antimony, ipecacuanha, and occasionally aconite
are useful in similar cases.
In some bkin diseases associated with deficient
activity of the sweat glands, diaphoretics are of
assistance in the treatment.
Perhaps the most important use of diapho-
retics has arisen from the recognition of the fact
that tho secretory action of the skin may be to
DIAPHORETICS
339
a certain extent vicarious Hence the value of
diaphoretic measures in acute or chrome neph-
ritis \\ith suppression of urine or indications of
the supervention of uramic symptoms Here
the use of the hot mustard pack 01 the hot
vapour baths, \vith such adjuvant measures as
have been already mentioned, may be sufficient,
but in many cases the powerful aid of pilocarpm
is called foi and proves of the greatest value
It is best administered m stn.ill doses hypo-
derimcally, the patient meanwhile being warmly
covered in bed If then* is any weakness ot
the heart, stimulants (sal volatile) should at
the same time bo administered intcinally
Diaphragm.
. 339
CONDITIONS IN WHICH INVOICED 339
PARALYSIS 339
SPASM . . 340
Nee ASPHYXIA (Aitifatai ReyHiaftan, Dfjtm-
sion of Diapht aam) , A si HMA (Nymjttomi, Xatuie
and Etiology, fyxwtH, of the Diap/ttaym) , CHEST,
INJURIES OF ( irotmrfs, Perforation of the Dia-
2>hiagnt) , liiccoudir, H\ DA no DISEASE (Eihino-
forcua of Liver ^ Displacement of Diaphtat/ni) ,
LUNG, TUHERCULOMH (Diarfnow, Jtontyen-Jtay
lllumituition, Dtap/ti at/mat ic Movement) ,
MUSCLES, DISEASES OF (Tuchima<n*, Imjuded
A<lion of Dutpfatu/ni) , Pos'i-MoRr*M METHODS
(Examination of Thin a e and Abilomen) , SPASM
(J/tftvw/h) , STOATACH AND DUODENUM, DISEASES
(Hub-p/uetuc Attire**)
THE Diaphragm, or Midriff, the partition between
the thorax and the abdomen, is a double muscle,
the two bides of which, though capable of inde-
pendent contraction, act m health habitually
together Its musculai fibies arise fiom the
lumbar vertobitc by means of the ciuia, from
the aichcd ligaments, from the cartilages of the
si\ lowct ribs, and from the posteuor suiface of
the ensifoim cartilage Aichmg upwards and
inwards these fibies converge on the tendon in
the centie Ovei the lower surface of the
diaphragm is spiead the peritoneum, ovei its
uppei the pleuiec and poiicardium It is
perfoiatcd in various places, and this allots
of the passage through it of the aorta, the
oesophagus, the vena cava, the splanchmcs, the
sympathetic, etc Tho diaphragm is supplied
mainly by the phienic nerves (each nerve
controlling one lateral half), and poihaps to
some small extent by the lower mtei costal
nerves
During mspnation the two latcial halves of
the diaphragm contiact simultaneously, thus
diminishing the curve of the arch and in ci easing
the capacity of the thorax The type of breath-
ing in women being chiefly costal, the diaphragm
is not so much used by them, and its excursions
are not so well marked as is the case in men.
Apart from the results of disease of the
phrenic nerves, the height at which the dia-
phragm stands is dependent on the relation of
the pressure in the thorax to that in the
abdomen When this relation is distuibed the
diaphragm is pressed upwards or downwards
according as the balance of pressuie is greater
on the abdominal or on the thoracic side Hut
as this displacement is of interest, not from the
point of view of the diaphragm, but from that
of tho viscera which are affected, the subject
Mill not be considered here Nor shall we do
more than mention that variety of pleurisy in
which the pleiiral covering of the diaphragm is
.iile< ted The same remaik applies to periton-
itis in which the peiitoneal covering of the
diaphragm is implicated In both cases the
musculai fibies may show some degree of
inflammation
No tumouis originate pumanly in the dia-
phragip, but that structure is often tho seat of
secondary growths Tubeiculous and malignant
processes are apt to pass from tho peritoneum
through the diaphragm to the pleura, more
usually, I think, on the right side of the body
than on the left The muscular fibie of the
diaphragm is liable, like other stuped muscle,
to suffei from fatty infiltration and from fatty
and hyaline degeneiation, and most probably
iheumatism may also attack it Gastric ulcers,
in which the peiitoneal surface of the stomach,
having become milamed, has attached itself
hi inly to the serous surface of the diaphragm,
may make their way thiough that structure
The main intciest of the diaphragm from a
medical point of view lies m the fact that it is
•in index to the state of the phrenic nerve and
its centre Under one set of conditions you
may have paralysis, under another spasm
PARAIAHIM — Apart from that paralysis some-
times seen in hjstena, and which is usually ot
little moment, the muscle may be paialysed by
any lesion of the phrenic nerve or of its centre.
Whether the paralysis affects one or both sides
of the diaphiagm depends, of course, on whether
one or both phrenic nerves are implicated
Tiaumatic lesions of the upper cervical vertebra,
tuberculous processes there, tumours, inflamma-
tory or other swelling of the meninges, may so
interfere with the phrenic nerves as to stop the
conduction of motor impulses and cause paralysis
of the diaphragm In then long and deep
course through the neck these nerves, though
protected from ordinary injuiy, may be divided
in cases of wounding, or seriously compressed
by tumours Even m their course through the
thorax the phrenic nerves sometimes suffer from
tho pressure of mediastmal tumours or are
involved m inflammatory processes
But, more commonly, paralysis *of the dia-
phragm is due to some affection of the whole
neuron Any of tho poisons, known and un-
known, \vhich produce neuritis may affect the
phrenic nerve Paralysis of the diaphragm is
340
DIAPHRAGM
behoved to arise from iheumatisin, though this
must be a rare 'xjcuirence It is seen moio
commonly m diphtheria, m alcoholic neuritis,
and in ben-ben, and the toxin of mfiuen/a may
produce like effects Tlio phrenic wive* may
be involved m cases of lead - poisoning , and
m progressive mubculai atiophy, amyotroplnc
sclerosis, and bulbar paralysis, the motor cells
of the phrenic nei\cs are bometimcs affected
and the diaphragm m this way paialysed In
cases in which the pleural or the peritoneal
surfaces covering the diaphiagm ate inflamed,
A certain degree of paialysis results To some
extent the defective movement of the diaphragm
m thebo cases is no doubt voluntary, and o\vmg
to the pain which movement occasions, it is
probably also m pait tetiev But it may be
due m some measuie to the inflammatory process
penetrating from the serous covering to the
bubstanco of the diaphragm, and there involving
the small nci ve branches in such a way as to
cause paralysis
Symptoms — When both sides of the dia-
phragm are paralysed there is no longoi to be
observed the1 normal protiusion of tho epigas-
trium on inspiration, indeed there is sometimes
«i sinking m m that region During expiration,
on the other hand, the epigastrium piotiudes
When only one phrenic nerve is paralysed these
signs arc unilateral So long as the patient lies
perfectly still there is little or no dyspnoea,
though tho rate of breathing is somewhat
.accelerated But on the least exertion dyspnoja
At once shows itself
Litten has recently pointed out that the
noimal movements of the diaphragm may be
readily recognised, especially m men, if the
thorax be carefully watched about the sixth
intercostal space As the diaphragm separates
itself from tho thoracic wall a shadow moves
downwards in a \vave-hke fashion over two or
three interspaces, and again i etui us dm ing
expiration To recognise this phenomenon the
patient should be placed in a recumbent posture
with the feet towards a good light The observer
should stand about thiee feet off with his back
to the light This sign might be of great im-
portance in investigating doubtful cases
Save m hysterical cases diaphragmatic para-
lysis is always of grave import, because any
pulmonary complication, even of a light nature,
is thereby rendered dangerous
The tientment is that of the malady in the
course of which the diaphragmatic paialysis has
appeared Blisters or hot applications over
the course of the phrenic nerve m the neck are
said to do good Occasionally stimulation of
these nerves by means of the faradic or of tho
galvanic cunent may be beneficial
SPASM of tho diaphragm may tako either the
tonic 01 the clomc form Of these the latter
is the more common.
Tonw I/ram of the diaphragm occurs m
bronchial asthma Tho centripetal impulse
passing up the \agus to the respiratory centre
is reflected down tho phrenic nerve, and so
causes a tonic con ti action of the diaphiagm, a
condition clinically recognisable by lowering of
the inferior bordeis of the lungs Apart from
that occurring m asthma, tonic spasm of the
diaphragm is an exceedingly raie affection It
lias been known to accompany rheumatism, and
to occur in cases of tetanus and tetany When
the diaphragm passes into tonic contraction the
symptoms are very striking Tho lower thorax
expands, the epigastrium protrudes, the liver IH
pressed down, and the lung border is lowered.
Along with these signs theio develops an extreme
and dangerous dyspnoja To counteract the
descent of the diaphragm the abdominal muscles
contract powei fully, and to diminish the dys-
pnoea the extraordinary muscles of respiration
come into vigorous action The patient also
complains of severe pain round the thorax at
the level of the diaphragmatic attachment
The condition is a serious one, and may provo
fatal The treatment must, theiofoic, be
energetic and rapidly carried out Some relief
may be obtained by means of fomentations and
sinapisms, and in a hot bath the spasm may
relax Duehcnno advised the use of the faradic
brush ovei the skin in the neighbourhood of the
diaphragm The administration of the nitrates,
of chloiotonn, 01 of a morphia injection may be
rapidly beneficial
Clomc rontofiction of the diaphragm, com-
monly kno\vn as hiccough, is much moie < omuion
than tonic spasm The contractions, M Inch are
usually fairly regulai, vaiy much in late, being
sometimes us slow as four or five in the minute,
and sometimes as frequent as one hunched The
spasm is not usually limited to the diaphragm.
The glottis is also narrowed and the nares move
Such constantly rccumng diaphragmatic con-
traction has of necessity a considerable effect on
respiration If the late of the luce ough is rapid,
there may be considerable djspiui'a, and even
the act of swallo \vfng may be interfered with
The patient is shaken by each contraction, there
is considerable pain along the diaphragmatic
attachment, and much exhaustion may result.
If the attack be prolonged — and some last for
weeks — the condition may prove veiy serious
Hiccough is due to irritation of the respuatory
centres, and this irritation may be peripheral or
central Tho peu/theral causes, which are the
commoner, include such sources of irritation in
the alimentary tiact as arc produced by stricture
of the (Esophagus, by overloading of the stomach,
by gastric or intestinal affections, by appendicitis,
by peritonitis, and by affections of the liver.
Disease of the bladder, of the uterus, or of the
prostate may, in the same reflex way, induce
hiccough Irritation of the pleura or of the
pericardium may act in a similar fashion Cen-
tral causes are seen in cases arising from cerebral
DIAPHRAGM
341
or spinal lesions, and m those which follow
strong mentul emotions, such as fear or anger
Poisoning of the nerve centres is piobably the
method of origin of that hiccough which allows
itself m such diseases as typhoid fever, septic-
aemia., and ureemia, and of the form which so
frequently precedes the lethal exit It is to be
remembered that m most cases of hiccough
a neurotic predisposition is present
As to treatment, it is clear that efforts should
be mado to remove the caiibe, if that can bo
recognised But, apart fiom this, it will often
be found that other forms of excitation of the
nerve centres may bung the attack to an end
Sneezing may do so, for example, or coughing,
or the exhibition of an emetic Holding breath
after mbpiration, and making a strong expiratory
effort while tlio glottis is kept closed, may be of
benefit The writei has seen steady pressuie
over the phremes do good in an obstinate case
of hiccough Galvanisation of these nerves
Nhould also be tiled, the positive pole being
applied cnci the nape of the nock, and the
uegatrve over the phrenic Hot fomentations
applied lound the lower thoiax and over the
epigastrium sometimes do good, 01 counter -
imtation may bo tried over these aicas with
benefit In serious cases it may be needful
to resort to moiphia, to ati opine, to chlorofoim,
or to nitrite*
Diaphragm, Surgical Affec-
tions of the.
ANATOMY 341
iNJUKIhS 341
DlAPTlKAGWATir HERNIA 3 t'J
Al'tF<'T[ONH 343
(m\ 343
ic Abtm 343
SUIM.ICAL AYUOM\ — The diaphragm is a large
dome-shaped musculo-tendiuous structure separ-
ating the thoiacic and abdominal cavities Its
muscular elements take origin below from the
bodies of tho upper three or four lumbar veite-
brso and their intervening discs, from the arched
ligaments which extend thence to the tram\ erso
processes and tip of tho last rib, from the caiti-
lages of the lo\\ei si\ ribs, and fiom tho back of
tho sternum They converge to be mseited
into tho strong central tendon, which is the
highest portion of the diaphragm, lying about
tho leu'l of tho lower edge of the sternum, 01
of the seventh chondio-sternal articulation Tho
vault of the diaphragm reaches to the level of
the fifth nb on tho right bide, and not quite so
high on the left Its nenoiw supply is denved
from the phrenic and sympathetic nerves.
On the thoracic side the pleura and peri-
cardium overlie tho diaphragm, while the
peritoneum lines its abdominal aspect
The continuity of structure of the diaphragm
is interrupted by three large openings for the
transmission of the aorta, the inferior vena cava,
and the oasophagus, and by snwllei foiamma for
the vena assygos minor, the splanchnic, and the
ts} mpathetic ner\ es Any one of these openings
may IKJ unduly large and so predispose to hernia,
that for the ojsophagus being the most im-
portant in this connection As bcaung upon
this point also, as well as on the question oi
perforation of the diaphiagm by inflammatory
products, Tillinann has drawn attention to the
iact that at coitam points the muscular tissue
is often dehuent, so that the pleura and peri-
toneum alouo keep up the integrity of the arch
Although these gaps vaiy greatly in size, shape,
and situation m diffeient individuals, then
pieseiue is fairly constant, the most important
being (1) that between the spinal and costal
ongins of the muscle, in relation to winch are
tho kidney, with its sin rounding connective
tissue, and the liver, (2) that beUeen the
costal and steinal iibres, over which the pleura
heu on the right side, and the pericardium on
tho left, (3) sometimes the sternal hbres are
entuely aw anting, so that a wide space is left,
over which lies the anteiior mediastinum.
In some cases the lower pait of the diaphragm
w exceedingly thin, more larely one half or
even the whole of the muscle is awantmg
INJURIES — Although traumatic lesions of the
diaphragm are by no means uncommon, they
seldom occur apait from mjimes of the viscera
which he in its immediate vicinity, and it is the
signs of damage to tho thoiacic or abdominal
organs which dominate both the pathological
and tho clinu al picture in these eases
Opm woumh are usually the result of gun-
shot injuries, punctureK, 01 sabre cuts As the
lung does not extend down as far as the pleura,
oi the pleuia as fai as the diaphmgm, it is
possible for tho diaphiagm to ho wounded alone,
01 along with the plcuia, while the lung
escapes
Subcutaneous t nature is commonest after falls
or crushes, but may lesult from seveie muscular
efforts, Mich as those of vomiting or partuiition.
The jagged end of a fractuied lib, or even an
unskilfully manipulated Oibophageal bougie, has
been kmwii to }>erforate tho diaphiagm
As this muscle never is, and ne\er can be, at
rest, its rounds either fail to close, or heal with
a thin, weak, and stietchable cicatnx, which
icadily favouis the formation of a heruial pro-
ti usiou
Cltmeaf feature*— So lai as the symptoms
of injury to the diaphragm itself can be dissoci-
ated from those of the concomitant visceral
lesions, they would appear to be loralised pain,
which is aggravated on deep inspiration or
coughing, and which leads to the patient re-
straining the action of the muscle as far as
possible Jtteedinq may take place from open
wounds either externally or into tho thoracic or
342
DIAPHRAGM, SURGICAL AFFECTIONS OF THE
abdominal cavities. Shock may be so severe
as to end fatally Risw satdonicun, which IB
supposed to be peculiarly related to morbid
conditions affecting the diaphragm, may be
present.
As a matter of fact, however, the dmgnow
of an uncomplicated injury to the diaphragm
is exceedingly difficult, and m the case of sub-
cutaneoub rupture all but impossible
The treatment can only be discussed along
with that of the associated lesions of the lung,
pleura, pericardium, stomach, etc (</ v ) One
of the great links attending such mjuiies is the
strangulation of any portion of the alimentary
canal which may become hci mated, cither at
the time of the accident or long afterwaids So
real is this danger that Stephen 1'aget advo-
cates a systematic attempt being made to close
such ruptures by introducing sutures from the
thoracic side of the rent The mwtoliti/ of
wouudb of the diaphragm is exceedingly high
(29 out of 33 cases ending fatally arcoidmg to
Krey), peritonitis, empy«ema, shock, or hamioi-
ihage being the commonest cause ot death
DIAPHRAGMATIC HERNIA — Any protnision
through the diaphragm is spoken of as a
diaphragmatic hernu, although in the vast
majority of cases— about 88 pei cent — there is
no hernial sac, and the condition is lathei one
of piolapse than of tiuc henna
MmM Anatotny —The protnision may take
place (1) thiough one 01 other of the natural
openings in the diaphragm, particulaily that foi
the cusophagus , (2) through one of the con-
genital deficiencies in the muscle, describee! by
Tillmann, (3) through a ruptuio pioduced by
indirect violence or muscular effort, or (4)
through a direct wound of the muscle
Laclier, to whose icseaiches wo owe much of
our knowledge of this subject, found that in
276 cases collected by him, only 28 presented
a sac, and of these 25 were congenital , and m
Bonn's collection of 80 congenital cases only 14
had a sac In round numbers, therefore, about
20 per cent of congenital cases have a sac, and
are therefore true hernia*, while only about 2
per cent of traumatic cMses can be so described
That the gieat propoition of diaphragmatic
profusions, whether with or without a sac,
should be situated on the left side is natural,
when we considei the substantial support given
to the opposite side by the liver, the fact that all
the large anatomical openings as well as the
congenital deficiencies arc towards the left side,
and that most suicidal and homicidal wounds
are aimed at the heart
Of 150 traumatic eases, 127 were left-sidod,
and of 117 of congenital origin, 98 wore on that
side c
The gi eater liability of men to accidental
and other forms of injury may explain the fact
that diaphragmatic hernia is five times commoner
in the male sev than in females
lar back through the
tendinous part of the diaphragm, but may be
met with else\vheie, particularly through tho
opening for the oesophagus It vanes in size
and shape from a mere slit or rounded aperture
to a complete absence of one half of tho muscle
As a mle, poi lions of more than one viscus
.110 piolapscd The lelative older of frequency
may be gatheied fiom the following — Stom«ich,
151 times, colon, 145 times , small intestine,
83 times , hvei, 45 tunes , duodenum, 35
times, pancreas, 27 times, cjocum, 20 times,
kidney, 2 times
It is mteiestmg to obseive, fiom the point of
view of opeiation, that adhesions between the
different prolapsed viscera or to the diuphiagm
seldom occui
Chntcal Featiue* — Children bom with a con-
i/enitaf diaphragmatic heima seldom live long
enough to manifest symptoms which lead to a
diagnosis If not still-bom, they usually sui-
vi ve but a tew houis 01 days, and the abnoi-
mahty is only discoveied on post -11101 tern
examination
On tho othoi hand, it is not uncommon for a
laige diaphiagmatu heima to be found at tho
autopsy on a pei son Avho has nc\ei manifested
any of the oidmaiy dmicil featuies of such a
condition In all t.ises, moieover, the dia-
gnosis is one of extieme difficulty, and appears
to have been made with accmacy only in some
seven out of nearly thiee hundred cases
The piommcnt featuies in well-marked cases
of some ttandnui aie (1) an unnatuial rlepics-
sion in the uppei pait oi the alxloiuen, with a
coi responding fulness in the lo\vei thoracic
legion (2) Well-maiked signs of an m the
pleinal cavity, simulating those of pneumo-
thoiax, aie piesent, vaiying in extent and
degree with the amount of the alnnentaiy tiact
which has l>een displaced, and the paiticular
\iscera involved Leichtenstem has suggested
th.it the amount of stomach in the henna may
be estimated by filling it with watei 01 air
from the mouth, 01 the colon fiom the lettum.
Distinct intestinal guiglmg may sometimes be
heaid on aust ultation of the chest (3) Tho
heart may be displaced and its action uiteifcred
with, causing palpitation, attacks of djspnu?a,
and a feeling of oppiession m the (hcst, with
inability to he on the affected side and cough
These phenomena also vaiy in intensity with
the size and natuie of the hoi mated viscera
(4) Vague and atypical symptoms of dyspepsia
aie prominent features ot all these cases Pain
in the epigastrium, heartburn, nausea, vomiting,
thirst, 01 constipation alternating \\ith diaiiho?a
aie commonly complained of Sometimes these
symptoms are woist after exertion , occasionally
a full meal gives temporaiy relief , and in some
instances the patient is conscious that the food
lodges in the legion of the chest, where it
produces a fixed pain
DIAPHRAGM, SURGICAL AFFECTIONS OF THE
343
When the henna is suddenly develojted the
predominant clinical feature is intense dyspncca
\vith severe piecordial pain, a sense of oppres-
sion, and an inability to he on the affected hide,
irritative cough, and a sensation that something
has given way Shock is marked, and may
prove fatal, or death may icsult fiom com-
picssion of the lung
A diaphiagnmtic hernia is liable to become
itrangulatet? eithei at the time of its pi eduction
or at any time theicaitei Some violent mus-
culai effort usually determines this event, but
in some cases it has been mevplamable The
patient presents all the chmc.il features of acute
intestinal obstruction, without, as a mle, any
guiding symptom to indicate the seat of
stiangiilation Hence the condition is seldom
iccogmsed dining life Huptuie of gangienous
bowel into the pleuial cavity will give use to
«ui empy.ema, and a cure may follo\\ its evacua-
tion by thoracotomy
Ti&itment — Vn established henna without
symptoms of stiangulation is so seldom dia-
gnosed that the question of deliberate suigic.il
mtoi volition scaioely arises It is only in cases
of recent wounds of the diaphragm, with pio-
1 1 us ton of visceia, and in cases of stiangulatioii,
that tieatment is possible, and then it is only
by operation that any good < an be done
(it) In *tu»t ItauntntH <'*s<s an attempt
should always be made to lestoie the displaced
\iscf »ia, after thoiough piaiiication, to then
place in the peiitoncal cavity For this pui-
jioso the wound may be enlarged as iai as
neccssaiy, and libs resected sufficient to give
lice access The lent in the diaphiagm should
at the same time be closed, and the opinion of
authonties is unanimous that this can best be
done from the thoracic side
When symptoms of stiangulation an- piescnt,
other points ai ise for i onsideratiou The prin-
ciples winch guide the surgeon undei these
uicumstanccs aic discussed in the next paia-
giaph, a jtrojHH of strangulation of an established
diaphragmatic heima
(/>) Strangulation of an established diaphiag-
matic heima is so seldom diagnosed that m
nuaily cveiy case any opeiation whicli is pei-
foimed will be in the iorm of «ui cxploiatory
lapaiotomy Even then it is by no means
certain that the* se.it of constriction oi the
bowel will be detected, and nurneious cases aie
on recoid wheie this has only been found aftei
death When the operatoi is foituuate enough
to recognise the obsti uction, howovci, authon-
tics aic agieed that the pleural cavity should at
once bo opened, by a U-i T-, 01 H -shaped
incision, with resection of libs, and the hermatod
}*>wel exposed before any attempt at reduction
is made, for the following icasons — (1) In this
way the fatal error ot drawing a piece of
ruptured or gangrenous bowel into the peii-
toneal cavity m a situation so inaccessible as
the vault of the diaphragm will be avoided
(2) The condition of the prolapsed viscus can
IKJ determined, and steps taken to purify or
icpair it, as may bo necessary, befoic its re-
placement (3) it is found to be both easier
and safer to i educe the henna by pushing fiom
alwve than by pulling fiom below (4) The
facility with which reduction is effected from
abovc» is doubtless due to the fact that the
admission of air abolishes the negative pressure
in the pleuial cavity (5) The thoracic opening
permits of the pun h cation and drainage of the
soiled pleural cavity, and so diminishes the risks
of empya?ma (6) The closing of the opening
m the diaphiagm is only possible if attempted
fiom the uppei aspect
While the opening of the pleiiia has these
suigical advantages, it must at the same time
be lemcmbeied that it adds to the alieady
senous condition of the patient the nsks in-
cident to pneumo-thoiax, and may tuiu the
balance against him
INF LAMMAIOKY API L( J IONS — Dtaphtnfjmntic
pleurisy olten closely simulates the onset of
acute peitorative peiitomtis and other surgical
abdominal conditions
An </&sfcss may foim in the substance of the
diaphragm, as occuired in Melt/ei's case, wheie
a young child sulleimg fiom pneumonia de-
veloped symptoms simulating those of empytema
Alter exploiatoiy punctilio with negative 10-
sult, the chest was opened, and a localised
abscess found m the diaphiagm
PerfotatiotHi howevei, aie miu h nioie common,
the diaphragm becoming sc-coudaiily involved
in innamm.it 01 y processes oiigmating in neigh-
bommg oigans
The pumaiy seat of disease may be m the
thoiax, in the tot in of empyoima, abscess, or
gangiene of the lung, tubeiculosis, suppurative
pencaiditis, 01 mediastimtis \ftei breaking
through the diaphragm the inflammatory pro-
ducts may entei the j)eritoneal cavity, giving
i isc to a sub-phi enic abscess , 01 mav pass
between the pciitoiieum and the muscles of
the back as a liimbai abscess, eventually open-
ing to the skm Where adhesions have formed
between the duphiagm and some poition of
the ahmentai^ canal, a purulent collection,
such as empytcma, may dischaige itself into the
bowel, and be voided by the lectum
On the othci hand, the diaphiagm may be
peifoiatcd from below, a sub-phi enic abscess
thus finding its way into the pleuial cavity,
lung, mediastinum, thoracic wall, pciicaidium,
01 even into the heait itself The peit oration
usually takes place thinugh one of the abnoi-
mally thin poitions of the muscle, through one
or other of the anatomical openings m the
diaphiagm, 01 at the seat of .idhcsions
Suu-PiTREXJO ABSCESS may oiigmatc m such
a variety of conditions that it is by no means a
lare affection Owing to the frequency with
344
DIAPHRAGM, SURGICAL AFFECTIONS OF THE
which such collections contain air the condition
is sometimes referred to as a " sub-phrenic pyo-
pneumo-thorax," a nomenclature which mvohes
a contradiction in teinis. Mdydl's table indi-
cates the different piimary causes of sub-phi emc
abscess, their relative frequency, and the pio-
portion of cases in \\lnoh there is air m the
abscess cavity
Out ot 179 cases collected by him, sub-
phrenic abscess oiignutod -
Contained
CI^PS An
In stomach and duodenum 35 20
, „ cfucum and appendix 25 8
„ hvei or biliary passages 20 1
„ mteinal mjimes IX 3
„ hydatid disease 17 3
„ the intestines 13 4
As a metastasis 11 1
In inflammation i omul kidney 11 1
„ unscellaiioous conditions 11 5
„ disease inside chest 0 1
„ exteinal injuries 6 0
„ caries of ribs 3 0
These collections m«iy be situated any \vheio
between the In or and the diaphiagm, but aie
commonest in the left hypoihoudrmm
Many ot these pnmaiy conditions may poi-
fortito the diaphragm without hrst foiming a
sub-phrenic abscess Thub Pick found that out
of 28 canes of gastric ulcer leading to peifoia-
tion of the diaphragm, 20 did so directly, while
only 8 fonned a sub-phrenic abscess Ulceis of
tho fundus of the stomach, especially if asso-
ciated with adhesions, tend to end thus more
than otheis Ulceis on tho postenoi part of
the stomach by contracting adhesions obliterate
the lesser sac ot the peutoneum, so th.it when
poifoiation takes place a sub -phrenic abscess
results
In appendicitis the pus may reach the dia-
phragm on the inner side of, or behind, tho peu-
toneum The suh-phionic abscess maj develop
very lapidly in acute suppmatne cases, with
perfoiation or gangrene ot the appendix, espe-
cially when no adhesions have fotmcd around
the crccum , but as a i ulc it does not occui foi
some weeks. Unless such an abscess is e^acu-
ated, cuily perfoiation of the diaphiagm is
almost sine to follo\\ Thus out of 25 cases 11
wcie not operated upon, and all peif orated Of
the 14 which were incised 9 were saved
Cltmmf Featmes — rriip comparative fre-
quence with which air occurs along with the
us renders sub-phi onic abscess very liable to
>e mistaken for pnoumo-thoraK or pyo-pncumo-
thorax , while many of the cases in which there
is no air closely simulate cmpyrcma
The onset May be acute, especially when due
to pci f oration of a gastric nicer, or thoie may
be little 01 no evidence ot the formation of a
veiy largo abscess
In addition to tho general signs of pus forma-
pn
be
tion, rapid or blow as the case may be, there IB
usually an excessive fulness and resistance in
the region of the epigastrium or loft hypochon-
drium, which often tends to point by the side of
the ensiform caitilage
The Inei dulness may bo lost on account of
the gas in the abscess cavity, and the liver is
otten markedly displaced downwaids by tho
pus The diaphragm, too, may bo pushed up
us far as tho thud 01 even the second nb The
heart also is often displaced
Clinical evidence of the existence of one or
othei of tho conditions which give riso to sub-
phi emc abscess, such as gastnc ulcei, hepatic
abscess, hydatid disease, ompyamiu, etc , is of
gi pat diagnostic value
As distinguishing this condition fiom tiuo
p}o-pneumo-thoia\, it is found Hint the hypoi-
ichouant note is lower in the thoiax, and ex-
tends into the uppei abdominal legions, the pirn
l)ing still lowei AmphoiiG bicuthmg and tho
boll-sound may bo pic-sent
When a sub-phrenic abscess has pcrfoiatod
into tho plemal <avity, the suddenness of tho
onset of thoiacic symptoms, with a pieuously
healthy condition of tho ( host, and the hwtoiy
of gas t nc, intestinal, Inei, 01 other abdomin.il
disease, lender the diagnosis fanly cloar
The^ww/wof/* is on the whole unfavourable
If left alone it usually piovcs tatal by setting
up cmpycenm, abscess of the lung, or peritonitis
K\en when it opens into the alimentary canal a
tatal issue is common
Treatment — The only rational and efficient
ticatmont is fiee incision and diamago
Tho causes, si/e, and site of these abscesses
ate so varied that no uniform method of oper-
ating is applicable to all The physical feigns,
supplemented, if possible, by an exploiatoiy
puncture, will guide us to the conect .situation
toi incision, which in all cases should be free,
and should peimit ot thoioughly efficient
drainage being established The adhesions
which foim round the abscess usually shut off
the general peritoneal cavity from infection
When the pus is on the convex surface ot the
liver, 01 on the uppci aspect ot the kidney or
spleen, access may be got through the pleura,
alter i ejection of portions of two 01 moie ribs,
with the ovoi tying muscle. The diaphragm is
divided, after the pleural sac has been shut oft,
by a circular scries of stitches It has been
urged against this method that the picssuie of
the largo tube necessary foi drainage may causo
necrosis of the adjacent nbs.
Although the results, even attci incision, are
not unifoimly successful, it has usually been
found that failure has been due either to co-
existent complications, such as pentonitiH, pneu-
monia, or metastatic purulent collections , or to
incomplete opeiation, such as neglect to drain a
concurrent empytema, an outlying loculus of tho
abscess, or to inefficient drainage
DTAPHRAGMALGIA OB DIAPHRAGMATALGIA
345
Dlaphragmalffla or Dlaphrag-
atalffla. — Neuralgic pain in the dia-
phragm.
Diaph rafflYiatltlS. — Inflammation of
the diaphragm
DIaphragmatocele. — Diaphrag
matic henna
DlaphthOra.— Putrefaction, especially
mtra-utenno putrefaction following fo)tal death.
DlaphyslS.— The body 01 shaft of ,i long
bone, forming fiom the primary ossifie oentin
PmsioioGY, Tissue s (Hone, JSjaphyvn ami
31")
316
346
347
Diarrhoea.
KTIOIOCH
YARIKTIKS
DIAGNOSIS OK Cvir.sii
I'l'IVIl'MGH OF TREATMENT
See Am, EXAMINATION OF ((hound An),
ASTRINGENTS, BRAIN, Al'l ETTIOKb OF IJl OO1>-
Yicsh&LS (CeitbtaJ Anti'nna, Cause*), CHILIUULN,
DbVhLoi'MENT OF (tfymjitom* <>t Teething) ,
CHOI ERA, Ei'iubvic , CHOLERA NOSTRAS , COLON,
J)ish\shs nt , CoNhiii'ArioN , ENEMAIA , (JAsruo-
IvifcSlINAL DISORDERS OF INFANCY (Dunrtwa,
bundle, Choleiau, eft), H\SIEIUA (Divmflert
of Dn/e^ti ve 0) iinn v, Pai ojcyunal Duinhaa) ,
IMFSTTNF**, DISFASES 01 (JKnteutti, Ulcer*,
Lnidaceom Z)i smsf, MaUynant Diwaw) , IJARDA-
C'HHJH D&(.KMi.RAlION , LUXO, TUBFRCUT OMH
OF (Comjiluatwn^ Alunentati/, Dmtthaa),
MALINGERING (Dn/tittre tiyifem, Dianhieti),
MhASLLS (GVmtsr), MhNhlllUMION AMJ IIS
DlNOHDEUS (VlCCUlOHt) , MFIhOROIXM.Y («SV«so««/
Kecutrtwertf Duinhual Afffttioni), MKSKM&KIC
GiAMNt (Tnttfitulrm, Clmtettl Venture*) ,
MuHn.Fh, DISKASKM OF (Ti tc/iimav^) , MYIASIS
(Intevttnnl) , NKi'iiunis (Arute, Chronit) ,
PB.LLAORA , PEMIMIK-US (Acute, Malignant) ,
PERIIONKUM, ACUIE PERiiONTii^ (Kymptom*,
Deflation, Dttnihvra) , PNEUMONIA, CLINICAI
(Chlldlwwf) , PlXAUMACOl IKiY , PRhSTRllUMl ,
RECITJM, DISEASES OF (ImjxtetioH of />KVS) ,
RHEUMATISM IN (JIIILDHEN, SPHUK (/////
Diaii/Mfa) , TABES DORSAUH (Iwtrvttnnl Cnw) ,
Tn\Roiu GLAND, MEDIO \ i, (Exophthalmic (/oitte,
Ditjetttve tfytfem) , TYPHOID FE\FR (Xi/rnptonn) ,
TRADES, DANGEROUS (Ltael-Poi*mtn</) ,
(Digestive fystem), WATER (Water -I'oi
DEFINITION —The term diaiihaM, which means
literally "a lunnmg through," is applied to the
frequent dischnigo of loose evacuations from the
bowels Tho too froquent passage of motions of
noimal consisttnico is not properly spoken of as
diarrhoea Diauhoca may be due to increased
peristalsis 01 inci cased intestinal secretion, or
both Although dianboea is, strictly speaking,
ft symptom only, theio are many conditions
where it is practically of sole unpoitance, in
which therefore it may legitimately be regaided
as the disease
ETIOLOGY —Amongst otiological factors
common to difteient foims ot diairhoca w/e is
of consideiablo impmtanee, for although diar-
iho)a may occur ot any age, it *s mr>st common
and much moie fatal at UK exti ernes oi hie.
Childion undei tho age of t\\o yeais aie \ei>
liable to dianhoja (to thn extent of fully tfO pel
cent of fatal cases), and in old persons a seven*
duirhoM ofton occurs as a terminal complication
in chionic wasting iliseascs The lemperahn e,
of tin1 atmospheie is .ilso of importaiifc A
sudden maiked fall m the temperatnie is apt to
be attended by a number of cases of diarrhoea ,
\vhilo dining the hot months of the year
ihildicn sutler se\eicly, and the nioitihty from
diarrhaal diseases vanes almost exactly with the
moan timperatuie While diarrhoea has not
IMUU sho\>n to \ary with the density of the
population, t/veinomlnuh want of clfanlinfs*,
iind esp(>(ially contamination of the fowl (milk)
^ujydy must be logaidcd as impoitant etiological
factois
SivnoMh — The passage of loose divine
e\ donations ^ith the Accompanying discomfort
may be the sole symptom piesent More
commonly gastiic disturbance, pain, flatulence,
and othci symptoms aio piesent as well
Chnmrtn ftf the «SYrxj/« — Tho nwnbn of the
evacuations >anes gieatly Then1 ma\ be only
t\\o 01 tin ce in the day, the jMtient feeling
quite TUP!! in the intervals, or theic may be
foui, h\e, or moic e\erj houi, and the feeling
ot discomtoit and desire foi a pash.igo may be
constant The amount of the e\ acuatums also
vanes within \*ido limits, fiom a comparatively
tiiHmg dischaigu to so copious a flux as to
lapidly dram the tissues of the body Tho
motions may be quite liquid and e\en \vatory,
01 may be of the consistence of thick giuel
They may contain scybalous masses resulting
fiom pi vcedmg constipation Fluid motions
die often descnbed as lesembhng "pea-soup"
(typhoid fevei), "nee uater" (choleia) ,
"sciapmgs of meat" (dysentery), "fiog-
spa\Mi" 01 "boiled sago" (dysentery with
copious mucous dischaigc) In "hcntciic"
diaiihooa tood tiken shoitly befoie is pissed
unchanged The colour of the motions ^allcs
according to the amount of bile present, and
also \\ith the natuic of the food Commonly
they are light oi dark blown 01 clay-coloured
They may bo black 01 tari^ fiom the piesence
of blood, 01 may be colouied by various drugs
(bismuth, non, hicmatoxyhn, etc ) The green
coloui so common m the diauhocas of children
may be duo to biliveidm 01 to chromogomc
bactena (the gioeu bacillus of le Sage) In
some cases the evacuations have an extra-
ordinal ily offensive odour duo to proteid de-
A cadaveric odour may develop
346
DIARRHCKA
in association with necrosis of mucous membrane
Mucus may be present in considerable abundance
m catarrhal conditions of the large intestine,
and the passage of mucous casts or " skins " is
characteristic of a condition dcsc-iibed as mucous
disease 01 mucous colitis Fat may be present
in the stools in consideiable abundance, some-
timcs largely in the form of fatty crystals, in
association with deficiency of bile (so-called
"achohc diarrlura ") 01 moic characteristically
of the pancreatic juice Pus, gall-stones,
cnterohtlis, intestinal parasites, fragments of
gangrenous mucous membrane 01 of malignant
tumours, may be discovered in the motions (sec
"Fieces")
Pain — Abdominal discomfort and even actual
pain are piescnt in most cases, usually most
marked in the lower abdomen, and dependent on
nrcgulai peristalsis of the intestine and flatu-
lence, parts of the intestine being spasmodically
contracted, while neighbour mu; paits are ovoi-
distended by gas Tho passage of the flatus is
often attended by rumbling noises 01 boi-
Ijorygmi. Where there is nrnch irritation in
the rectum defecation is often attended by
severe tencsmus
Fever — In ordinary simple diarrhoea fever is
either absent 01 slight and tiansient, but many
of the diseases which cause dianhoea aie highly
tebnlc
Constitutional — When laige liquid motions
succeed each other lapidly as in choleraic
diarrhoea the tissues aic drained of fluid, the
secretions, especially the saliva and the urine,
aie ai rested, and the piticnt suffers severely
from thirst, and soon sinks into a condition of
collapse
THE VARIETIES OF DIAUUIKEA — Diaiihcva is
a symptom of so many different luthological
conditions that it is impossible to give .1113
natural classification of the varieties mot with
For convenience the following groups may be
recognised —
(1) A Luge number of cases aie due to local
irritation, ausmg especially from the mgcstion
of impropei food Hero we may also include
diarrhoea due to excess of bile or to absence of
bile , to intestinal concretions , to intestinal
paiasites, to puigative dings, and to certain
irritant poisons A choleraic diarrhoea may
icsiilt from arsenical poisoning In these cases
the nutation may lead to increased penstalsis1,
or to intestinal hypertcmia and catarrh, or to
slight 01 scveie inflammation of the mucosa
(2) Certain iorms of diarihoca have long been
recognised as elttm native, especially the diarrhoea
of uuemia Diarrhoea considered to be of this
chaiactei has been described as occurring m
rheumatism, ckabctcs, gout, and in certain
feveis, especially confluent smallpox, influenza,
pucipeial fever, and stroptococcic infections
Diarrhoea due to exposure to cold is possibly
sometimes of this iiatmo Watery diarrhoea
may be present during the disappearance of
ascites or other effusions.
(3) Nervous (psychical) influences may give
rise to diarrhoea, for example in persons about
to undergo a surgical opeiation
(4) Many instances of diarrhoea are microbic
in origin Under this heading are included
those due to toxic substances arising from
putrefactive piocesscs in foods and bevciages
(meat poisoning, cheese poisoning, etc) The
specific 01 gam sins of typhoid fovet, choleia,
cholera nostras, certain forms of dysentery,
tubciculosis, may be found in the stools
Sevcial outbreaks ot dianhoca have been
attributed to forms of the bacillus enteritidis
(Gardner) The diagnosis of malai lal diarrhoea
has been made by the discovery of Laveran's
plasmodmm in icd blood-corpuscles contained
m the stools Diarrhoea has been attributed,
pei hjps somewhat doubtfully, to certain
Rhizopoda (monadmes) and Infusoria ((Vrco-
monas intcstinahs, Tiichomonas mtestmalis,
Paramcecmm coli)
(3) Diaii hoja may be wondat if and associ.ited
with luflammation 01 even ulceration of the
mucosa of the small or Luge intestine Such
inflammation may be (a] cataulial, arising in
the course of the specific fevers, as a teiininal
process in \\astmg diseases, or as a result of
portal obstruction , (b) croupous or diphthci-
itic , 01 (r) ulccrative, as in tubercle, cancel,
dysentery, typhoid fevei
Chronic Diarrhoea — Chiomc diarrhoea may
follow an acute attack 01 may develop in-
dependently It is usually associated with
intestinal catairh due to one ot the conditions
already mentioned Intestinal catarrh as-
sociated with poital obstruction is not un-
common in elderly people, and is associated
with diarrhoea, debility, and anomua Marked
depression of spirits may also bo present
Mucous diarrhoea (mucous colitis) is a very
chiouic affection, but the seventy of the
symptoms vanes greatly from time to time It
is characterised by the passage of the mucous
casts spoken of above, and in some instances by
severe eiitcralgia
Tropical diarrhoea is a generic term applied to
several forms of chronic diarrhooa \\luch are apt
to afflict Europeans who have been long resident
in tropical climates,
DIAGNOSIS — Occasionally patients complain of
dianhoja who do not suffei fiom diarrhoea at all,
but simply from some local irritation about the
anus or roc turn When diarrhoea is piescnt the
important point in diagnosis is to ascertain its
cause If the attack is acute it may be pos-
sible to trace it to some indiscretion in diet, or
to some special article of food which may have
given use to intestinal disturbance in all who
partook of it, or to exposuie to cold If the
diarrhoea is very severe, and attended by pain
and vomiting, the possibility of its being due to
DIARBHCEA
347
initant poisoning, whether from putrefactive
alkaloids or from inorganic poison, must be kept
in view. Amongst articles of diet which have m
many instances given rise to (severe diarrhoea
may be mentioned pork-pie, veal-pie, sausages,
tinned meats and fruits, stale oysters, crabs,
cheese, ice-cream
lu chronic diarihcva a systematic examination
of the evacuations, paying attention to the points
mentioned in the paragraph on the " Charactei
of the Stools," is of the nist importance Micro-
scopic or bacteriological examination may lead
to a coricct diagnosis Obviously the existence
of any present or past disease winch may be the
cause of the diairhtra must he ascci tamed
Digital examination of the rectum and examina-
tion with Kelly's rectal speculum will often gue
nnpoi tant information
The diagnosis of the part of the bowel chiefly
affected is usually difficult, and often impossible
In catanli of the small intestine there aic often
severe colicky pains, and the stooh are gi oyish-
yellow 01 ochieous, not \eiy frequent, and may
contain partially digested food There are no
definite symptoms of duodenitis, but it is usually
associated with gastutis, and often with jaundice
When the large intestine is affected, pain may
be absent, or may be \cry intense The evacua-
tions ha\e .1 soupy consistence, and may contain
large quantities of mucus Their jia&sage may
be attended by maiked tencsmus if the lower
p.ut of the bowel is aflicted
TUFA i MBNT — Atute Dim thna — Acutedietctic
duuhuja requites little treatment in slight cases
except rest and abstention fiom solid food, but
in most cases recovery will be hastened by the
administration of a pm^atneas soon as possible
aftei the onset of the attack For this purpose
half an ounce of castoi oil with 20 01 30 diops
of laudanum is a favoiuite piescnptiou A dose
of rhubai b is pi efei led by some If the di.iri hcva
still continues twenty-four hours after the action
of the purgative, an alkaline stomachic mixtuie
with cat initiatives may bo oidercd, 01 model ate
doses of aiomatic chalk powder, chalk mixtuie,
ot bismuth If vomiting is present as well as
dianhoja, ice maybe given to suck, and small doses
of bismuth and pulv ipeeae co <id ministered at
intervals of a few horns will be found useful
Where small motions are being passed frequently,
and accompanied by a good deal of in i tat ion of
the rectum, an enema of one or two ounces of
staich with 20 to 30 diops of laudanum should
bo given
Other foims of acute duuiluca should be
tieatcd on similai lines. Rest in bed, waimth,
and the icstiictwn of the diet to milk 01 bland
fannaccous food oiten make the patient com-
paratively comfortable even when the evacua-
tions have previously been veiy numeious
In nervous diairhcca, which is usually ic-
current, the patient should be taught to restrain
the impulse as much as possible If about to
be exposed to any condition likely to bnng on
an attack, a dose of bromide of potassium may
be administered beforehand
Chronic and tfecondaiy Diati/wa — In all
cases the diet must be attended to, and all
aiticlcs ot food which are not being properly
digested must be forbidden In some forms of
tropical diarrhoea rest in bed and the absolute
rcstnction ol the diet to milk is found to be the
most effective treatment Piolonged lest m
bed is often the best remedy for chronic diairhau
in hysterical women
A diet icstrictcd moie or less stuctly to raw
meat IN found useful in some forms of chronic
diariha-a
Whcie diaiihoea is associated with acidity of
the intestinal contents, chalk 01 caibonate of
bismuth may be oideied with some of the
vegetable asstimgents, and with or without
opium In some cases, and especially when
there are frequent watciy dischaiges, the mineral
astringents will succeed better, sw h as the per-
nitiate 01 perehloiidc of non, sulphate of copper,
or nitiate of silvei
Antiseptics have been much used of late m
the tieatment of diaiihau of miciobic oiigin,
and may be tiled in any case whcio the odour
of the evacuations is veiy offensive Peihaps
the most successful method of pioducing some
appioach to asepsis in the bowel is to give one
or two puigatne doses of calomel followed by
the continued admmihtiation of salol in full
doses Such tieatment, howc\oi, is obviously
unsuitable for many cases of chronic diarrhoea,
but < alomel in icpcated small doses, caibolic acid,
bunodide of mcicuiy, naphthaline, /3-naphthol,
saluylate and suhgallute of bismuth aie all
useful
Wheic the mischief is chiefly in the colon,
daily iriigation with a large quantity of fluid
should be cairied oat For this purpose salt
solution (one diadim to a pint) or a 1 per cent
solution of boiacic 01 salicylic acid may be
used
If nlcciaticm of the colon is picsent, astnngcnt
injections aie often of the gieatest value, such
as nitrate of sihei in the pmpoition of a diachiu
to two pints of waim watci
DiarthrOSlS. — A joint allowing motion
in all dnections, a ficc arthrosis
DiaSCOpiC Method.— The method of
diagnosing the nodules of lupus Milgaris by
piessing apiece of glass on them , the accompany-
ing h>j>ei.eima can thus be made to disappcai,
but not the nodules (Uunit) tiee SKIN, TUBKRCU-
KfelbO* (Lujm*, Ctttiic
. — A feiment dusting in malt,
which, acting upon biokcn staich granules, con-
verts them into dextim and maltose, in the
process various dextnns (differing in their rota-
tory power, and in other particulars) are pro-
348
DIASTASE
duced. See PHYSIOLOGY, FOOD AND DIGESTION
(Carbohydrates, Maltose) , TKMPERAIURE (Eleva-
tion from Injection of Diastase)
DlastaSlS. — Separation of two contiguous
bones or muscles (««/ diastasis of the recti
muscles of the abdomen, diastasis of the head
of tlio hunicrus from tlie shaft, etc ) The word
is domed From Oi Siaoracm, standing apait
DlastematO-. — In compound words
dia&temati)- ineaas »cforrmg to a congenital longi-
tudinal fissme Thus diavtemntnchetlia is a
longitudinal fisHine in the middle linn of the
lip, diaktemntotyttia is a longitudinal median
fissure of the urinaiy bladder , rfiaiteuMtomyelta
is separation of the spinal cord into two lateral
strands in the whole or (more often) in juit ot
its extent, etc
Diastole. — The relaxation - phase (( J r
StaorcAActi', to expand) in the action of the
heart *SVe I'IIYMOUUM, Cnirui AHON (Carthm
Cycle, /V/rtso)
Diastrophe.- A distoition 01 dofoinuty
Diathesis. >^<> <//s« API-END KM us (Etuh
lofjy, Ji/tfunmtK Diathesis), BUONCHI, Jlno\-
cmm (Etiology, Diatheses), CACJIKXIA , Co>.sii-
TUTION, (iour, HEMOPHILIA, lllMKIHA, I>-
HA\m, NAIlTlth AND S\M1'WMS, LYMPHATIC'
SYSTEM, l*lIWOIOd\ AM) PAIHOU)^ (Lywphtt-
denonut, Lymphoyenw Diut/te*i<>) , TUIIKIU ULOMS ,
etc — This teim, derncd fiom the (Jieck worls
But and rt0i//u, may be defined as the predisposi-
tion 01 constitution of the body, in virtue of
which ceitam of its tissues or organs become, at
one tune or succcHhivuly, the seat of affections
similar in then nature, these affections piesent-
mg for their oiigm no other moie potent or
more definite cause The natuie and meaning
of diathesiN c«m probably best be explained by
the following considci ations
In oidoi that a human being should li\o
through the noimal numbci of yeais, doing
dining this peiiod the ordinal y amount of woik,
and exposed during this penod to the oidmuiy
risks fiom cold 01 mjuiy, it 's necessary that
each oigan and tissue in tiat being should
possess, from the beginning, a proper amount
of what is called vitality It is evident that if
any one of these tissues 01 organs baa been
endowed at the beginning of life with less than
its propci amount of this vitality, its stoic must
become exhausted previous to that of the otheis
A moic or less localised lueakdown will then
ooeui, as the lesult of which the A\hole being
will suffer, 01 perhaps even the continuance of
ife will be icudered impossible .lust as the
i>eed of a fle*t is dependent mainly on the
fe'ed of the slowest vessel AJX it, so the duration
puhfe is dependent mainly on the store of
DiaJty possessed by the weakest of the tissues
somoans of the body \
It is known that, as the result of differences
in the surroundings and modes of life amongst
mdnidual human beings, the wear and tear of
life is not always equally distributed over the
different tissues and organs. In one individual,
for example, the heart and blood-vessels aie
specially strained, in another the bionchi and
lungs, in a thud the kidneys, m a fourth the
nervous system, and so on It is known, further,
that the amount of vitality with which the new
being is endowed at conception is dependent on
the Mtahty of the patents Hence it follows
that, although the offspring may bo always
potentially bcttei than the paients, if the parents
have lived undei unhealthy conditions, if they
have been weakened by disease 01 accident, or
it they ha\e been immatmc 01 too old, then the
store of vitality transmitted to all or certain
oi the tisbucs 01 01 gins of the otfspnng will be
deficient Hence it w ill follow that, as the result
of no h|X( idl ovcibtiain 01 no excessive exposure
to cold 01 other moibid cause, a pTcmatuie
bieakdow n w ill occui This, foi obvious i easons,
will tend to show itself specially in one or other
of the tissues 01 organs, hcait, lungs, nervous
system, kidney, etc, and so, as the lesult of
disease affecting one 01 othei ot those paits, the
individual will be cut oft long befoic the noimal
peiiod of life is leached
The piecise natuic of the disease changes
uhich affect these paits is apt to vaty It
may be an inflammatoiy change puie and simple,
like a iH'phntis, it may be an inflammatoiy
change due to the entrance of some oigiinism,
as a tuberculous phthisis 01 an endocarditis , it
may be a so-c tiled deueuciation, as a fatty heait
or an atheroma, 01 it may be a ne\\ giowth, a
cancer In all cases, however, the gieat import-
ance of the tissue Mtahty has to be home m
mind, and although it is always difficult, and
oft times impossible, to say w hethei the simound-
mgs or the eoiiHtitution.il condition has been the
mote impoitant factoi in causing A disease,
theie is no doubt that the capability of the
phxsician to prognoso and alleviate depends
largely on his powci of recognition and proper
perception of the lelationship between these
twTo
1 he duration of life being dependent on the
power possessed by the tissues and otgans of
the body to maintain themseUcs against disease
changes, and the diathesis being the piedisposi-
tion to disease changes inhcient in certain of
these tissues or oigans, it is evident that the
number of diatheses should theoietically be xeiy
gieat This number, indeed, should coi respond
not only w ith that of the tissues or organs, but
also, at least to some extent, with the diseased
conditions to w Inch these tissues or organs are
liable Hence, as can readily lx> understood, a
vciv great number of diatheses has been de-
scribed Among these the more prominent are
the gouty, hthwnuc, rheumatic, strumous, scrofu-
DIATHESIS
349
lous or tubercular, cancerous, nervous, inflam-
matory, gangrenous, scorbutic, hocmorrho,,
But a moment's consideration will show that
this number is by far too large Many of these
are simply modifications of the same diathesis,
others are to be regarded as diseased states rather
than constitutional predispositions 01 diatheses
Jn this article, therefoie, detailed reference need
only be made to a few, and by this selection an
additional advantage is obtained in that only
those diatheses aie deseiibed which aie moio
or less readily iccognisable by objective ap-
pearances
(Joiity — In this diathesis the individual pre-
sents, at least until the middle pciiods of life,
all the indications of lohust vitality and of great
bodily and mental activity The fiame is \v.»ll
built and well noinished, though tending pei-
haps somewhat to fatness A^ might be ex
ported, the digestive and assimilative poweis aie
excellent, tlic teeth aie good, the skin of the
face is flond, ovei the tiunk it is lathei thick
with active glandulai oigans, the hau is abund-
ant, showing, hovvevei, lalhci eaily a tendency
to turn giey Owing to the excellent assimila-
tive and digestive povvei, and the feeling of
well-being and fitness which such a diathesis
tonfcis, gouty individuals aie rathei liable to
excess in eating and dunking, and a tendency
to a ninio 01 less plethonc condition supervenes,
v\hi(h in time gives use not only to the special
nouty changes in the hbious tissues, but to the
occuiience of allied inoibid ch.uiges in the heait,
aitenes, notably the ceiebial ones, unnaiy
oigans, etc Theic is no doubt, ho\\evcr, tliat
in its slightci degiees, should the tendency to
excess be guaidcd against, this diathesis is one
vvhu h is prol>ably moic than any other associated
with long life and bodily and mental vigoui
Insuiance statistics seem to show that a family
histoty of gout in oiten found amonirst the best
lives, and the saving of Sydenham that "moic
wise men th.in iools have suffeied from gout"
seems, if piopeily mtcrpioted, to bear this out
A somewhat goutv habit is theiefoie not infre-
quently an advantage in life Its disadvantages
arc indirect, being the lesult of its tendency to
lead to excess, and consequently ovei strain ui
the excretory organs
Rheumatic — This diathesis is one which to
some extent leseiublcs the gouty The nuh \ idual
is usually well built, well nouiished, and mus-
cular, having good digestive and assinnlativ e
povvcis Hut the blood and circulatory oigans
seem to picsent a lack of nutntive. vigour The
checks aie often mddy, but it is to be leiucm-
bercd that this may mean the levcisc of the
cxubeiant health which it might at first sight
indicate Professor Lay cock used alwajs to
teach his students to be distiustful of a very
healthy-looking complexion
In rheumatic individuals the innate weakness
in the blood often shows itself in caily life by
BUjHirvention of antenna, especially in females,
the corresponding faulty condition of nutri-
tion in the heart and blood-v cssels bypndocarditic
changes Moreover, as the result of compaiatively
trifling exposures, the charac ten >tic inflamma-
tions of joints, seious sin faces, etc, arc apt to
arise
ticnjfufav* — This diathesis, which compiiscs
the strumous and the tuberculai, is one in which
probably all the tissues and organs of the body
have been endowed with an abuoimally low
degree of vitality, but in which, owing to this
cause, the absoibent sm laces anil the glandular
oigaus «no specially pi one to suflci fiom the
eutiauce into them of the tubercle oigamsm
Its «ib|i<ctivi> charactenstK s can piobably best be
des.nhed ny folloAiug the oldei wnters, and
cousidei in}.' it as divided into two classes — (a)
s<iotulouh, uid (b) tubeiciilous (Jenncr), or as
tlu'^c li,,v • been aptly enough, though not quite
1 01 reedy, tciincc], the ualy suofula and the
pretty scioful.i
(a) tictofuhmv — Of this the following were
the chaiacteiistics as given by the older w liters
~h i»u re heavy, abdomen laige, ends of the long
bones rather laige, shafts thick, skin thick and
opaque, complexion dull and pasty-looking, face
plain, lips and ale of nose thick, lymphatic
glands very peiceptiblc to touch, tempeiament
phlegmatic, mind and body luthaigic Although
certain distinct diseased conditions have been
( onf used with the diathesis in this description,
piobably in kets and possibly t letimsm, the above
yet foiins a plot me which is, to a considciable
extent, tine to lite
(b) Tuhnculott* — To this m its tuni were
ascribed the following chaiacteiistus — Figure
slim, adipose tissue small in amount, ends of
long bonus small, shafts thin and ngul, limbs
stiaight, skin thin and tianspaient, complexion
clear, superficial veins distinct, blushing frequent,
ejes blight, pupils laige, eyelashes long, hair
Milken, face oval, good-looking Clnldieu the
subject of this diathesis aie pi ccocious, cut their
teeth, inn about, and talk eaily In adults the
neivous svwtein is usually highly developed, and
the mmd and body aie specially actne, so that
this diathesis is pi ac tic. illy moie or less identical
with the ueivous It is not to be ioigotte.ii,
fuithei, that with it theie is often associated a
fan amount of musculaiity and a considerable
amount of physical stiength With it, as with
the sci of ulous, howevei, the constitution is faulty
and the liability to the supcivention of tubeicu-
lous diseases oi all kinds is gre.it
Of the othei diatheses the so-called cancel ous,
the hcoibiitic, and the hamioirhagic require
mention only The fust of these cannot readily
be distinguished diathetically (%c " Tachexia") ,
the othei two aie in icality foims of disease
n artificial alkaloid,
of a " double nitrogen ty pe," having the formula
350
DIAZOBENZENE
C0H6 N N.O1I ; it closely resembles tyrotoxicou,
the toxic ptomaine which has been isolated from
poisonous cheese, milk, or cream Dia/oben/enc
sulpboinc acid is used in testing urine (wtfc infra)
See also TOXICOLOOA (Cheese)
DlazO-ReaCtlon. — Khrhch's dwzo-ie-
action may bo obtained as follows a few CLS of
urine are put in a test-tube , an equal quantity
of a saturated bolution of sulphamhc acid in a
solution of hydrochloric acid (50 cc to 1000 cc )
is added , then also <in equal quantity of .1 half
per cent bolution ot sodium mtiite is added ,
the whole is then shaken , next 1 cc ot ammonia
is run alowly down tbe side of the tube and
forms a coloiulcss zone above the urine, and it
the urine be normal a brownish ring is pro-
duced where the two iliuds meet, but 111 certain
coses a deep brou<n(<<h-i ed ung forms (the diazo-
reaction) , the foam of the mited urine and
reagent w biowmsh yellow in noimal mine, and
rose-red when the reaction is present The
diazo-rcactiou is not a < ertum test for typhoid
fever, for it is found also in malaria, tubcn ulosis,
and typhus. See Luxo, TUHKUCULOSIS (Cowph-
cations,Uio-gemtal, Pi oynous) , MALAitiA(/>V?m/?i
Tertmn Fever, Unne ) , Tiwius FEN EH (Penal
of Advance).
Dibasic Acids and Salts. Acids
(eg sulphuric acid) are dibasic when they con-
tain (in each molecule) two atoms of hydrogen
replaceable by a base , salts arc said to be dibasic
which are formed by the replacement of two
such atoms by a base
Dibothrlocephalus Vulgar Is.
See PARASITES (Centode.*, Bothi ioce}>haln* latus)
DlcephalUS. — United twins or double
monster, in which the t\vo heads and gencially
the two necks are separate See TFUATOIAJGY
(United Twins, JDicepfuttic)
DICheilUS. — The congenital anomaly
known as "double lip", it is due to the pies-
ence of a fold of mucous membrane on the
innci .\spcct of the upper or lowei lip, giving
to it the appearance of duplicity (Ballantyne,
Antenatal Patholoyy, \ol u p 390)
DiChlruS. — The raie teratological state
known as fused or double hand, in which there
arc more digits than normal (7 or 8), but, as a
lule, no thumbs, and in which there may bo two
ulna instead of a radius and ulna in the forcaim
tal Pathology, vol n p 586)
DlchloracetlC Acid.— Acetic acid in
which two atoms of chlorine have taken the
place ot two ufaoms of hydiogen in the acid
radicle , acetic acid is CH3COOH, and dichlor-
acetic acid has the formula CH012COOH, it
usually occurs in the form of a vciy caustic
liquid
Dichotomy.— The division of the fee
received by an operator or a consultant between
iiniHelf and the general practitioner who has
called him in , a reprehensible practice fiom the
itandpomt of piofessional ethics
DlChrOiSftl. —The property of a substance
t>y which it has one colour when viewed by
transmitted light and another by dncct light
DlChromatOpSla. — Colour-blindness
which only two of the pruuaiy colours can
be distinguished, in contiast to monochioma-
topsia, in which the uholc spectium appears in
shades of one coloui (e y green)
Dicroccelium Lanceolatum. See
i'\RA.sirES (]] elm tnths, TreinatotJes)
DlCrotiSm. Ste PULSE (Intei jn etatwn
and Value of the tfphyymogram, Diciott&m atuJ
Ifyperdtn otnm) , PH\SK>LOO\, CIRCULATION (At-
ml I'uhe, Pul*e Wave)
DlctyOld.- Reticulated, trom <*r SLKTVOV,
a net, and etSos, foim , thus dittyopsia is the
moi hid state of vision in which net-like objects
aie seen bcfoie the eyes
DidaCtyllSm. — The malfoimation of the
hand in which two digits alone aie found ,
bidactyly , "lobstei-tlaw detoinuty "
DidelphyS.— The uteiu* dMphys is the
most complete tonn ot double uleius, there
being two separate laterally-placed halves, each
of which, howevei, has only one ovary and tube
attached , the vagina may be single or double
Dldot'S Operation. See DEFORMITIES
(Hand and Finf/etn, fyndactyhun, Treatment)
Dldymln.— Tewticulai substance, recom-
mended in sterility, neuiasthema, etc fiu>
iNDKiESfioN (Treatment, Neivou* Dyipepita)
DlencephalOn. — The mter-bram or
thalaniencephalon in cmbi}ology
Diet.
FOOD
351
351
KKO.UIUKMENTH IN HEALTH
MODIFMNO FACIOUS —
Aye and iSVr, Height, Wwk and Rest,
C/inuite, Personal Pendiattties 353
RELATE K VALUE OP FOODS 354
ANIMAL FOODS —
Meati, Jelhei, JieeJ Jwce*, /<W* 355
MILK AND ns PIIODUPTH 358
EGGH 359
VEGETABLE FOODS —
GWifo, Pulses, Root* and Tubers,
Green VegetaMe*, Mutts, Fungi, etc 359
MINERAL CONSTITUKNIM OK FOODS 363
BEVEKAGEH 363
See o/60 ADOLESCENT INSANITY (Treatment,
Diet), ALCOHOLISM (Treatment, Personal), Ar-
DIET
351
pENDicrns(3fVeafrne!7i*), BERi-BEHi(G'aww), CON-
STIPATION (Treatment, Diet), DIABETES MKLLITUS
(Treatment, Dietetic), GAHTRO- INTESTINAL Dis-
OKDEIIS OP INFANCY (Infantile Dtairkoea, Treat-
ment), CASTRO-INTESTINAL DISORDERS OF INFANCY
(Constipation, Treatment) , GOUT (Dietetic Treat-
ment), HEART, MYOCARDIUM AND ENDOCARDIUM
(Treatment, Diet) , INDIGESTION , INFANI FEED-
ING , INVALID FEEDING, LIVER (Gonyettion, Treat-
ment) , LUNC., TUBERCULOSIS OF (Therapeutu,
Dietniy), NURSEU\ II \GIENK (Ditto) , OnEsm
(Treatment), PmsioLo<.\, FOOD AND DIGESTION
(Diet and Dietetics), PREGNANCY, MANAGEMENT
(Diet) , PUERPERIUM, I'm HIOLOGY (Diet) , 1'UER-
PERIUM, PAiHoixxiY (»SV/>?/f rt-wi/a, Diet), Scrn\\,
INFANTILE (Etioloyy, Treatment) , SPRUE (Treat-
ment, Dietetu) , SioMAdi AND DUODENUM, J)is-
JiiAS&s OF (Gencial Etiology, JSnwi in Diet),
Tiriioii) FKXKR (Treatment, Diet), UNDULAM-
FEVER (Treatment, Diet)
A FOOD may be defined as an} thing which, when
taken into the Ixxly, is able either (1) to build
up 01 icpau tissues, 01 (2) to supply matciial
for thu pioduetion of heat 01 inuhcul.u \vork
A true food niUHt thcrofoie be cithci <i tissue-
builder or a somce of potential cncri>} J)ietotic
substances which aie unable to fulfil eiLhei of
these functions tuay ha've impoitant actions on
the body, but cannot be regaided as foods in the
true sense of the tcim Such substances are
tea, coflec, and the extiactnes of meat
THE NUT RHINE CoNsrnutMs oi ioods maybe
at landed thus —
Oigamc'—
fl'iolcids, r ij iiiyosiu oi me it.
casein oi milk
Albuminoids, « g gt l.itine
Caibohydidtcs, e y sugais and
starch
Jats, e y butter
Inorgimc —
Watu
Mineial matteis, i y sodium, potassium , calcium
and magnesium , iron , phosphorus, chloiiiK,
sulphui
The functions oi food as building matciial,
iuel, .ind a supphei of energy, are fulfilled by
these diffeicnt groups of nutritive constituents
in varying measuic
ttutldiiHj material is supplied by the proteids,
watei, and nuneial ni<itteis, and by these alone
Fats, carbohydrates, and albuminoids <ne unable
to foim tissue Seeing that theie is always a
ceitain amount ot wosto of bodily stiiicturc
going on theie is .1 constant demand foi these
matciials in the diet Without them, 01 any
one of them, life is impossible
All the w (/ante nutiitive constituents of food
serve as sources of heat They are able to do
&o in virtue oi their capability of undergoing
oxidation in the tissues and organs Fat requires
the greatest amount oi oxidation, and is there-
fore the most potent fuel food Pioteids, caibo
hydrates, and albuminoids aie about equal as
heat producers, but are scarcely of half as much
value as fats The standard of heat production
is the Calorie, which means the amount of heat
required to raise the tcmperatuic of one kilo of
water 1° Cent.
It has been found by experiment that —
1 gramme of proteid hilly oxidised pioduu i 4 1 Gals
„ ., caibohydiate ,, ,, 41 „
iit „ 9 1 „
It is no doubt owing to then gieat value as
lie.it pioduccis that fats iiud such a Luge place
in the dietaiy of the inhabitants of very cold
climates, e (/ the Esquimaux The presence of
40 pei cent oi fat in the milk oi the walrus is
.in instance ot a sumlai <tdaptatum on the part
oi Natuze
As law material for the production of muscular
enen/y the carbohydrates arc no\v admitted to
lank hi&t It seems ceitain, however, that the
pioteids can eithci dnectly oi indirectly serve a
similai function, and piobably the fats aio able
to do so too Whethei the albuminoids are
able to fill a similar iole is uncertain The
giuat utility oi sugar cspucialh, as a muscle
iood, has icccntly been insisted upon by many
obseivcis, and its value is continued from such
diverse sources as laboiatoiy experiments with
the eigograph, the efficiency of troops on the
maich, and the experience of Alpine climbers
It will piobably AMU foi itself a laigei place than
it has as }et taken in the dietaiy of ttainnig
Notwithstanding this outcome of modem le-
seaich the necessity of a hheial supply of
pioteid in the diet of those who have to pci-
form seveie muscular woik must not be lost
sight of Sticnuous muscular cxcitiou is always
accompanied, soonei or latei, b} an increased
excietion oi urea Whcthci one regaids this as
arising fiom the utilisation of proteid as a
souice of eneig\, 01 asdibes it simply to the
distinction of muscle iibie which severe work
necessaiil> entails, the loss still requires to be
made good That is the physiological justifica-
tion foi the high opinion which trainers have
always ontci tamed of a nchly pioteid diet foi
those engaged in athletic contests
It is evident that the pioteids are, by them-
sches, capable oi fulfilling all the demands
upon a ( ompletc food They are able to build
and lepau the tissues of the body, to supply it
with heat, and provide the muscles with pabulum
foi their work It is this physiological omni-
potence which gives to the proteids that pre-
eminence which thoy possess amongst the
nutiitive constituents of food, and thanks to it,
life can be maintained on a diet oi lean meat
and watei, as in the Sahsbuiy cuie, for a
pioctically indefinite time
Tiifc AMOUNT OK FOOD REO.UIHKD IN HEALTH
— An idea of the quantity of food required
daily in oidei to maintain the body in a state
of health can bo armed at either by a physio-
logical or an empnical method The foimcr is
352
DIET
based upon estimations of the intake and output
of the chief chemical constituents of the food,
and of the amount of potential energy expended
daily in the production of heat or muscular
•work The Litter is founded upon a simple
analysis of the diet* of healthy peisous, living
under known conditions, and neithui mci easing
nor losing in u eight Dietaries based upon the
results yielded by the thst method are called
ttandatil dietaries , those which letmlt fiorn the
second are actual dtetatte*
(1) The chief chemical elements which the
physiological method has to take into consideia-
tion are nitrogen and caibon A healthy man,
of aveiage \\eight and doing a modeiate amount
of musculai woik, cxcietcs fioni 16- JO gi amines
of mtiogcn and about 320 ot carbon daily In
other woids, he "will icquire e\eiy day to be
supplied with about \ ot an ounce of nitiogen,
and '4 lb of caibon, or one pait of the former to
every sixteen of the lattoi The approximate
proportion of caibon to nitiogcu in some common
articles of diet is as follows —
Roast Beef has, 1 of Nitrogen to 5 of Caibon
hav 7
Milk
Pease
Broad
Potatoes
has
have
ha*,
have
10
11
12
28
Evidently none has mtiogon and carbon in
proper piopoitum For this reason one must
cithoi adopt a mixed diet or consume an undue
amount of one 01 othei element The former
alternative IH the one usually adopted, and is
illustrated by the following staudaid English
diet (Oliver) —
335 21
Such a diet moie than supplies the amount of
carbon and nitrogen icquncd
Taking the output of heat and work .is the
basis of calculation, it is found that a man
doing moderate muscular work requires a supply
of potential energy equal to 3000-3500 Calories
daily The next question is, what fraction of
this total is to be provided in the form of pro-
tcid, carbohydrate, and fat icspectively ? As
icgaids proteid the reply is easy The amount
must be suthcient to provide 20 grammes of
nitiogen Now one pait of nitiogen is con-
tained m 6£ of animal and 6-5 7 of vegetable
pioteid , Hence 20 x 6 25, t e 125 grammes of
proteid, \\ill be an ample allowance The
lelative proportions of caibohydrate and fat arc
not so easily determined, for we have no means
of knowing how much of the total CO2 excreted
daily is denved fioni the oxidation of the one
and how much from the othei All we can do
w to distribute the balance of Oalones not
obtained fiom pioteids between the two m
ace 01 dance, as far as possible, with the lesults
ot actual obseivatioii of the usual amounts of
each consumed by healthy men As a matter
of fa< t, the data given by different authorities
on this point aie conflicting, but 103 gi amines
of fat and 4 JO of caiboh^diates may be le-
gaidcd as a fan allowance, einng, it anything,
in the direction of an undue piepoudciance of
fat Thc&c amounts \\ill piovulc a total of
3211 Caloiies distzibutcd as follows -
Tioteuls
Fats
Caiboli>di ites
(\ilorn ^
125 grammes x 1 1 - 5125
105 „ x93 = 9765
120 „ s 4 1^17220
3211 0
Such a diet might be made up as follows
(Atwatei) —
()/ (Moms
8 -560
4 =^230
-135
2} = 565
-.J25
8 =160
2 =205
9 -720
Total
(2) A large number of actual dtetai tes have
now been investigated, especially on the Con-
tinent and in Amenca, the lesults of the more
important of which are collected by At water in
the tollowmg table —
Beef
Fish (mackerel 01 hc>
tibon
N it i Op, « ri
2 BILL'S
117
55
Buttei
75
Cheesi'
84
Milk, 1 pint
Potatoes
4*>
1 3
Hue
20
1 7
Brtad
15
2
Sugai
20
3
DIET
3r> 3
ACTUAL DIETARIES
Nutrients
lofirititl
flissci
i
"
1 m i JTV ' >J
, Plot PI,
, Plt 1 {'uln
rats llodiuhs
Total
^lltII(nta
Eiimpfit n and Japanese diUanei ) dims
dims | dims
f dims
( iloius
1 Setting girl, London, wage* 93 cents (3s 9d ) per week 53
2 Factoiy gill, Loutsic, Germany, wages $1 21 jicr week , 52
3 Weaver, England, time of srauity . 60
4 Laboureis, Lnmbaidy, Italy , diet mostly \egetablo 82
') Tianpist monk, in doistci , vwy littlo c \cicisu, vegetable
33 316
5 J ' ,{01
I 28 j 308
10 1 3(52
102
406
486
184
1820
1910
21 -J8
2192
diet . < bh
11 ' 4bO
548
2304
6 Students Japan 97
16 ' 138
551
2343
7 Univeisitj picifpssoi, Munich, Germany, very httl« ,
1
CX01C1SC ' 100
100 240
140
2324
8. Lawyu, Munich 80
lli"> 2l!2
42;
2401
9 Physician, Munich , Ml
yr» t-27
27b2
10 1'AintPi, Leipsic, Gu many 87
h'J libit
522
2500 ,
11 Cibimtinaku, LIIJISU, (initially 77
12 "Fully led * tailois, England ' 1.11
W r,?,
600
2717 ,
3053 '
13 "\Vfll-]ui<l ' imihaiiif, Mnuuli, (j(iuidn> , 151
;»i 179
b81
11 Cdi pcnti i , Alunuh, Ginuany i 1*31
68 1'Jl
bUi
3194
!,"» " Haid \\oikcd ' \iravu, Kngland 1«">1
43 (>'J2
blO
J560
16 Bldcksmith, England . 17>'>
71 RfiT
•HI
4117
17 Minoib al Miy <^i \«ro \\oik, (rtrmauy 1J3
in MI
v*»0
1195
18 Bink-mak( rs (It.ihans at < ontiac t uork), Munii.li 107
117 l>7'»
M'iQ
19 Hiu\vi>iy labouid, .Munich, vi-iy sovcio voik, « \tLp-
tionaldnt , 22 *
m ' ooo
121,".
r.69'2
20 dt mi tin >.oldicit, p» ict footing j 111
id 180
6i'i
279t>
21 ( Jei man solditis, war footing 131
58 480
681
3093
22 Gennau solrluis, Frinco- tJcnnan "\\ar, cxtiaordmary 1
2«3 ill
77J
46 ',2
It \\ill bo ohhOiM'd that tlicM? conobpond
moie 01 less tlo&ely, both m thi1 piopoitions oi
then imtnhvo conbtitwntb.UKl the total amount
ot potenti.il cncijjy yielded, \vith the phywo-
logical icqum'tnt uts .ihoady laid do\\n and
exemplified 1)> tin* standaid die tuics desciiU'd
.ibovc
Houtjhly hpc«ikinj>, a man \\ho adopts one of
the ulunc stain l.ud diets \\ill consume about
3 Ibs of solid food cLul>, containing about 23
o'£ of diy solidb, or neaily an ounce per hour
The amount ot mmeial ni«ittez and Avatci nvhuli
he leq uncs will bo considered later
It must be deaily realised that such st.ind.ird
diets .u e only ot limited applicability They
cannot be rigidly enfoiccd in all eases and undci
all uicumbtauces They aie useful, howevci,
OH fiunishing one with some idea of the amount
and kind of nu turnout which should be supplied
to .1 healthy man doing a model ato amount of
woik Thus they aio of gicat assistance in
con sti acting diet tables for public institutions
m whuh the inmates aie unable to have a free
choice of foods, as, for example, m prisons,
workhouses, hospitals, and the like In apply-
ing them to nidn iduals respect must bo had to
various modifying factois, of which the chief
are age and sex, height and build, \\ork and
rest, climate and suiroundmgs, and, last but by
no means least, peisonal peculiarity The in-
fluence of each of these may now be briefly
considered.
iMi l<'ACioito — (1) Aye and /S'ej —
Childicn lequne iclatively moie building
material, fuel, and muscle food than adults
Thc> leqnue moie building matciial because
they must not only keep then tissues in ir>paii
but add to them by gio\\th the) leqmre moie
fuel because, like all small auimaN, they ha\c a
huge surface oompaied to then bulk, and so
lose heat lapully, the) lequne moie muscle
food because of then lestlessness and bodily
activity m pla)
Hence childreii icquiie a laige amount oi
food, and the impoitame of pioteid and fat to
them especially can haidly be o\ei -stated With
the aged the i e verse h< >lds gc KK! The assimilati\ e
po\vei of then tissues is on the ^ane and then
bodily activities icstuctcd, hence their diet
should be s mallei than that oi middle hie
One may easily undeiieed the young, but one is
apt to toiget that it is almost as casv to o\n-
feed the old Women leqime lelatively less
food than men, not only on account of the
lightei natnie of then >\oik, but also, probably,
fiom then possessing a slo\\ci lale of metd-
bohsm Roughly 4»eakmg, a \soman may be
regarded as requiring only tS paits of food to
every 10 requned by a man
AH compaied \vith the food of* a man at
moderate \\oik, the piopoitions foi children
may bo stated thus —
354
DIET
A child under
,, fiom
3 to 5
6 to 9
10 to 13
14 to Ib
14 to 10
2 lequnes 0 A
04
05
06
07
08
(2) If eight anil Build —These have a dctei-
mmmg influence on the amount of food requited
by affecting (a) the body weight, (b) the extent
of body surface The greater the weight of the
body the greater the amount of food icquired
for its upkeep Thus the heavy man leqmies
moie food than the light man
The number of Calories which rcqunes to be
supplied per kilo of body weight .ire about as
follows —
Duung icst . 30 to 35
,, light work 35 to 40
„ moderate work 40 to DO
The gieatei the extent oi body surface the
more lapidly heat is lost and the laigci the
supply of fuel requiied Foi tins icasnu the
tall thin man who has a large suiface lequnes
moie food than the short stout man who has,
luhitnolj to hi* weight, a much smallei suiiace
(3) TToiX and Ke*t —Those two factois have
a more potent influence on the amount ol food
requited than any otlioih The necessity for a
large supply of pioteid and carbohydiate during
the performance of sc^eie bodily labom has
ahoady been pointed out Tlie numbci of
Calories icquiied under such conditions may
use to 4000 or even 1500 (for examples, bee
Table I )
On the other hand, when the body is at com-
plete rest, as is the case, foi example, with an
invalid lying in bed, the demand for potential
energy may fall to 2000 Calories or less per
day Intellectual work does not appieciably
increase bodily waste, and therefore does not
demand .1 hboial diet Quality, and especially
easy digestibility, is a much more important
consideration ior the brain woiker than meie
quantity
(I) Climate is piobably of less teal impoit-
ance in detei mining tho actual amount of food
icquired than is commonly supposed Fluctua-
tions in external temperature should be met by
diminishing heat loss through increase of the
clothing lather than by increasing heat produc-
tion by ( hangos in the diet Notwithstanding
this, experience seems to show that in cold
climates and m winter the fuel foods — and
especially those rich in fat — should be increased,
\v hile in the reverse conditions tho carbohydrates
should be relatively increased, and the proteids
and fats diminished The blubber diet of tho
Esquimau^ on the one hand, and the rice diet
of the Hindu on the othci, aie examples m
point
(3) Personal peculiarities as affecting tho
amount of food required are largely to be ex-
plained by the influence of body weight and
shape already considered When all deductions
are made, however, there is still room for the
popular belief that some people can " get on "
with less food than others, though both are
living under the same conditions and performing
the same work Of this fact, if fact it be, theie
is no satisfactory explanation , but it is at least
conceivable that some organisms arc more
economical machines than otheis, and turn
their supplies of potential eneigy to better
account, just as a man who has had piaeticc
will perform a given muscular feat with much
less weai and tear than a novice Such indi-
vidual peculiarities may explain the tendency
to obesity in ceitam families, and must nlwajs
be boi ne in mind in regulating the diet oi
patients
THE Km* vin E VALUE OP FOODS — The iclatne
value of diffeient foods must bo decided on
chemical, physiological, and economic grounds
(1) The chemical value of a food is deter-
mined by the icsults of its percentage analysis
The composition of most of the foods in common
use is set out in detail in the tables in the latter
pait of this article It need only be lemaiked
heie that one cannot judge of a food from its
chemical composition alone A food which con-
tains but a small percentage oi nutiients can
ne\cr be icgai (led as a valuable article of diet,
but, on the othoi hand, the possession of high
chemical qualities by no means ncccssaul>
implies suitability to the needs oi the bodj
(2) In judging ot the 'value oi foods on phy-
siological grounds one has to consider (a) the
digestibility of the food in the stomach, (b) its
absorption in the intestine A good focxl is one
which is easily digested and well absorbed into
the blood
(a) Tho ease with which a food is digested m
the stomach may be gauged by the time which
elapses before it is passed on into the intestine
This time is occupied in bringing the food into
a state of solution, and the more rapidly this is
accomplished the greater is the digestibility of
the food in question As the results of ex pen-
mcnts upon men the commoner foods may be
arranged according to the length of time w hich
they remain in the stomach, as follows —
1 to 2 hours
7 o/ watei or plain tea, coffee, 01 cocoa
,. beet or light wine
„ boiled milk
„ beef tea
Whites of 3 eggs
2 to 3 hours
I mnt watei, beer, or boiled milk
A laige teacup ful of coffee with cieam, 01
< ocoa ana milk
'2 law or poached eggs
.<i oz raw meat
9 „ boiled calves' biains or sweetbread
2& „ raw oysteis
5 „ boiled white fish
7 „ cauliflowei or asparagus.
DIET
355
r. o/ bulled 01 uiaslied potatoes
2£ „ white bioad, old or no\\
2i,, tusks
2 „ biscuits
3 to 4 hums
8 o/ stewed chicken 01 ioast paitudge
9 „ boiled beef
beef steak
of any soit of brc id 01 biscuits
or rice, spinach, apples, orcaiiots
4 to 5 houis
o/ lodht bci-f in steak
A study of the table will be of assistance in
making such a selection
(3) A good food must not only con tun a high
percentage of nutrients, and be easily digested
and well absorbed , it must also be cheap One
may best aitive at the relative economic value
of a food by calculating citlici the total numhei
of Oaloiics or the amount of building material
obtained in it for a given sum Thus one finds,
proceeding on the first plan, that a shilling's
\\orth of —
10 „ „ duck
r>4 „ mashed Itntils 01 stewod 1-ieuch beans
7 „ „ pets
The aiticles in the fust t\\o gioups aie ob-
viously those which make least demands upon
the digestive po\\ei& of tho stomach
(If) The capability which a food has of ab-
soiption in the intestine must be clcaily distin-
guished fiom its digestibility m the stomarh
The most easily digested foods aie by no means
uecessaiily those which an1 most completely
absoibed and cue t'tma The following table
'chiefly aftei Kubner) shows the dci-iee towhieh
;hc imtiituc constituents of some typical foods
aic absoibed —
Wheat Horn yields 1.3,782 Calories
OitmiMl „ 9,189
Putatoes „ 7,689
Hcans „ 7,630
Fat salt poik ,, 6,8?5
S'lgai „ 6,292
M.ugmne , 6,161
Chu.si „ 3,o42
liuttei „ 5,082
Milk , 2,178
Log of mutton l,07o
Hit lom ol bed , 870
KgKs ,, 708
Cud lish ,, 650
Tf tlic amount of pioteid obtained b taken
as the stanclaid, one gets such 10 suits as these
1 Ib of pioteid m peas costs 7cl , oatmeal, 7J,d ,
bicad, Is Gd , milk, 2s 2d , beef, 2s 8d
1 I1' MI nt iv InilisiiilMil
I*.,. 1 - ---
Turn"11 |1">t111' Jlt ! hulVrt,
Kief 11 20 4 'OH
Wlufa Ru id 12 21 8 ' 11
Mioaium 1 J 17 1 12
Boiled Bed . 19' 2 b '
Roast „ ' -i I 26 '
Eg<rs ,12 26 14
Milk 88 71 r> J
Cheese '64 .53 ft 2
Mwe i 67 r»5 J2
Pe.it, <M i 17 5 .i b
Whole Mval Hit id U 1 ' 36 7 7 <* '
Potatoes (Maslud)! 9 i .50 5 71
Cabbage | 14 Q 185 IS 1
Cdiiots 207 i^O ' 18 '2
A "lance ,it the tables \\ill sho\\ that both as
legaids the total numbei of Calories yielded
and the amount of building mateiial obtained,
the vegetable foods are very supeuor to animal
pioducts Amongst the cheapest of the lattei
in both respects aie cheese and milk
It must be clcaily realised that the maxim
"cheap and nasty" docs not apply to foods
Hmh pi ice and high nutnti\e Aalue aie not
synonymous The price of a food in the
maiket is delei mined mote by such considera-
tions as flavoiu and lanty than by chemical
composition 01 digestibility Thus a pound of
ctxl at thieopencc yields just is much nourish-
ment as .1 sinulai quantity of sole at eiuhteen-
penro , and common anowroot sit foui pence is
of the* same ihoiiiic.il and physiological valuo as
Heimuda at t\\o shillings
It will be obsened (1) that the caibohydiates
and fats aie much moie completely absoibed
than the pioteids- indeed, it may be said that
the fat of the diet is absoibed almost entirety,
\\hile the onl) foods in whieh thcie is any
appieciablc loss of oubohydrates aie green
vegetables and, to a less extent, the pulses,
(2) that -vegetable pioteids are not neaily so
well absoibed as those of animal oiigm It
must not be supposed that it is desirable that a
food should be completely absoibed into the
blood The contrary is the case The intestine
demands a certain amount of insoluble lesiduc
or "ballast" to seive as a stimulus to its peii-
tttalsis Hence tho advisability of selecting
foods which leave a considerable residue for
cases of constipation, and of those which are
very completely absorbed in oases of diarihwa
AMMAI FOODS
1 ^feat — The flesh of animals, which con-
stitutes moat, consists of muscle fibres held
togcthei by connective tissue The fibres vai v
in length and thickness If they aie long and
coarse, as in the leg of A ciab, the meat is less
easily digested than when tho fibres are shoiter
and moic delicate, as m the b least of a chicken.
The fibics contain the muscle plasma, 01 "juice "
of the meat, the chief ingicdicnts of which are
watei, the pioteid called myosm, a certain
amount of haemoglobin, certain "rf)\ti active"
lx)dies, the best known being creatm, and some
mineral salts, chiefly compounds of potassium
and phosphoric acid Kigoi mortis is due to
clotting of the myosm, and meat in that condi-
tion is tough By and by acids are developed
356
DIET
in the meat which soften the myosm, and the
meat becomes tender again Meat should there-
fore be eaten either hefoic ngoi moitis has
supervened 01 after it has* passed off
The connective tissue of the meat consist*, of
the substance called "collagen," which is con-
verted into gelatine by boiling The connective
tissue is more abundant in old than in }oung
animals, and the flesh of the formei lequncs
moie cooking to conxeit the connective tissue
into gelatine than that of the latter does Em-
bedded ni the connectne tissue is a ceitain
amount oi iat In some kinds oi meat, such as
pmk, the fat is abundant, in otheis, such as
paitndgc and chicken, it is almost absent In
swimming birds, siuh as the duck and goose,
too, the amount ot fat between the fibies is
relatnely laige Fat so placed tends to hindei
the access of the digestive juues to the fibres,
and impaiib the dig« stibihty of the meat It is
well to foibid such meats to the dyspeptic The
chemical composition of the whole ot the meat
taken together is approximately this -
Witn
N it i oai'THWs
M tttoi
Iat
Minn
Al itti i
I>m
761
21
1 5
1
Muhum
730
J0r> '
-.6
1
Kiit
r.3 o
17 '
UOO
1
It will be obseived that the tattci the meat
the i>oorei it ib m \\atei Fat and watei are to
a laige extent mutually teplaccable Houghly
speaking, tlnee-touiths oi ordinal y meat consist
oi water Of the mtiogenous mattei, about 1
pel cent consists oi "extiactnes," and J to 3
pei cent of albuminoids, such as collagen , the
icbt consibts of proteid.
The objects ot cuolint/ meat aie (1) to develop
its flavoui , (J) to impioNc its appeaiance by
destroying its led colouung mattei , (3) to
steubse it and so incieasc its keeping piopeities,
and dimmish the iisk of inflection by any disease
germs or paiasitcs \\hich it may contain The
principles to be obseived in canying out these
objects «ue — (1) to heat the meat to a tempera-
ture suihcieut to stenhse it, and destioy its led
colouring matter without o\er- coagulating its
proteid , (2) W) couvcit all the connective tissue
as fai as possible into gelatine, (3) to effect
these changes \vithout lemovmg from the meat
any of the " oxtiractne " matter to which it owes
its flavour InVairying out the fhst punciple,
it should be borne in mind that the led colour-
ing matter^of mtiat is destroyed, and the pioteid
coagulated, at a tempciature of 170° Fahr, and
that to go above this bimply tends to haiden
the meat by ovei -coagulation In stuving as
far as posbiblo to convert all the connective
tissue into gelatine, one must remember that
meat is a bad conductoi, and therefore the heat
should be applied to it slowly, and gn en plenty
of time to act upon the collagen The third
object —the conservation of the flavoui ing m-
giedients of the meat — ib to be achieved by
" sealing up " the meat by a bi let exposure of
the biiiiaee to a tempeiature sufficient to sud-
denly coagulate all the superficial layeis of
pioteid, and bo pievent the subsequent escape
of the extractives The methods by w Inch these
principles aie successfully earned out in piactue
aie descnbcd m the aiticle on " Invalid Cookciy,"
but it may be pointed out hcie th.it the} aie
best attained by heating the meat (aJtei the
pieluuin.uy sealing) foi a long time to a teni-
peiatme not exceeding 170 Fain , and that the
method of stewing 01 bi. using IN mo it in accoid
with coil eft pi in< iples ot cookeij than any other
The digestibility ot meat is not impio\ed by
any metluxl ot cooking Indeed, it nwy be laid
down as a geneial mle, to which then, are few
exceptions, that cooking diminishes tin digesti-
bility of annual foods and menaces that ot
vegetable pioducts Tin tiulh of this as le-
gaids meat is boine out by UK follow ing obsei-
vations of .lessen -
i\ o/ ot i iw belt an digfstcd in 2 limns
,, half boiled bed UIM!I# sttd in J[ limns
,, wholly boiled bttf me digested in «J Imuis
,, half loastid b«cf au rhijt'stiil in 3 boms
,, \vbollj indited bcel die digested m 1 liouisv
,, IAW mutton ill i, digcslLil in 2 bums
,, id\\ \oal aie digi-stul in 2\ horns
,, i.iw poik die di<r(>st(d in <J boiu-
As has already been pointed out, me.it is
absorbed m the intestine M*I> completeh, <>nl>
about 3 pei cent nl its di} nuittei bomi; lelt
behind
The ease of digestion oi law mc.it and the
smallness of the lesidue \\hich it leaus in the
intestine lender it a iood ot special \alue m the
tioatment of eeitam .ilh'ttions ot the stomach
and bowels It is best picpaird bj sdaping
the libies away fioin conncctixe tissue which
holds them togethei b^ means of the back ot a
knife The pulp so piepaicd may eithei be
adminibteied in the foim of a sandwich, oi, if
that is inadmissible, it may bo stiind into a
small quantity of beef tea Celeiy salt is a
useful flavoui ei Cakes of such beef -pulp,
lightly bi owned on the surf. ice, foim the basis
oi the " Sahsbuiy " cine
The composition of some oi the internal
organs of animals used as food is .is follows —
Kidney
Livci
Ht-ait
Lung
Swectbioud
Tripe
W itci
iNiti (.>,;< nuns
Matt, i
hi
7(J7
16 9
48
098
21 6
54
626
1(50
204
797
16 1
.) 2
700
280
02
716
16 i
85
DIET
357
Owing to then dense structure, kidiiey, livei,
and heart are difficult of digestion Tin1 lungH
< ontam a large amount of indigestible elastic
tissue Blood is also sometimes used as food,
but it contains only 18-23 per cent of solids,
«md is not well absorbed The presence of
much nucleo-pioteid in all of the above organs,
except the hc.ut and tripe, makes it prudent
tor the gouty to avoid their use, seeing that
nucleo-pi oterd is «i bouif e of uric «icid
Jellu s are derived fioin gelatine pioduced
by boiling the collagen of connective tissue
Noting tissues, e y calves' feet, aie the most J
abundant source Isinglass is a pine foim of
gelatine demcd fiom the sw mi-bladder ot the
sturgeon, but it is lathei expensne, and does not
ically go faithei than oidmary gelatine Com-
meicul gelatines (P (/ Nelson's 01 Cox's) aie as
good as any other for feeding the sick The
nutritive \alue of jelly is consideiable Six
ounces (a large helping) of good jelly yields
1-j o/ of solids, oi which about one -half is
gelatine, tho iest being sugar This must lie
lemernbeied in ordering jelly foi diabetics
Gelatine bemu the best "protoid-sparei," jelly
is an admnable food foi febnie patients.
The " ex ti.u lives" of meal are the main
constituent ot SWM/JS and ?*pff ejftfH'tv Tlie
physiological action of these extractives may be
stated thus — (1) They vield no potential
eneigv, and aie theiefoie not foods (2) Thev
have no power of iu« leasing the late 01 forte ot
the heait Then "stimulating" effect on the
ui dilation i"* to be attributed to the hot \\atei
with which they aie taken (3) It is doubtful
it they ha\e an\ stmmlatmn iiction on the
iieiNOiis system, but they appeal to remove the
Jeehny ot i.itigue (4) They taste ,ind smell
ngreeabl}, and .ue, theiefoie, powerful aids to
digestion by helping to call ioith a secietion ot
gastric JUKC (0) When taken in e\ce*s they
are apt to excite diaiihcea
Hence rleai soups, which consist ot a solution
of the evtiactives, have no nutritive value, but
are useful at the beginning of a meal The
same may be said of beef -tea as oidinauly pie-
pared The following is tho Litest analysis of
Liebig's extract (Kemmeiich) — Water, 18 pel
cent, pioteids and gelatine, 30 pei cent, ex-
tractives, 33 per cent, mineral matter, 20 pei
cent , ether c*xtrat t, 7 pei cent
It vull l»e obseived that it contains a con-
siderable amount of soluble pioteid, but .is a
teaspoonful of it only weighs 5 ginis it can
never be taken in sufficient quantity to be of ical
•value as a food The same maybe said of those
preparations, eg Boviil, to which some of the
powdered fibie of moat has Insen added The
large amount of salts VN Inch beef extracts contain
is of very doubtful advantage, for there is no
proof that the demand foi salts is increased m
fevers, or that tho mineral matter bo supplied
can bo made any use of
ice* are prepaiations which contain the
coagulable pioteid of meat The method of
making law beef juice is described elsewhere
It usually contains about ."i pei rent of proteid
The amount in commercial beef juices varies
from 20 per rent 01 moiefcy \ itaha) to con-
sideiably liss than 5 pei cent (r rj Valentine's),
but the major it\ do not (ontam much more
coagulable pioteid than tholiome-modc article
The large amount ot extiactives and mineral
mattei in the commeicial JUKCS is a positive
disadvantage, as it lendeis it impossible to
<tdmnustei them in an v considerable quantity ,
foj th.it reason home-made juice is to be pie-
feiied lietf juue is sometimes a useful ai title
ot diet in diarihaa (especially in ( luldren), but
it is rbihcult to .idmuustei an, thing like .in
adequate Mippty of nutnment m that foim
alone
/Wi — Theie aie t\\o classc* of hsh — fat and
lean Lean hsh is hiuh as contains lesh than
2 pei cent 01 fat (ft/ sole, floundei, whiting,
haddock, ccxl, and tiout) Of the fat fishes,
mullet, halibut, and nmckeicl contain fiom
2-5 per cent ot tat , tin1 salmon, turbot, herring,
and eel contain moie than 5 per cent The fat
hshes aie about ccjiial in nutritive value to a
sinnlai \\cight of modeiately fat beef, the lean
fishes aie poorer in nutirents than beef, and
i ontam lelativel} nioio water and gelatine All
fish is poorer in "extiactives" than meat, and
foi tins reason Irsh is a less stimulating foim of
tood than meat, and is sometimes preteiable to
the 1 ittei in some diseases, t // epilepsy Lean
hsh is usually easilv digested owing to the shoit-
ne&s ot its hbies and the absence ot fat , foi this
reason it rs suited to invalids Fat fish is
difficult to digest, and the oil in it is apt to
become i.incid and nutate the stomach It
should be avoided b) d \speptics The belief
th.it fish (onlams much phosphoius, and is,
theiefoie, pecuhail} suited to biam vvoikcrs, is
entiielv unfounded
Allied to fash are lobsteis, dabs, and oysteis.
These have tin4 following composition —
Nitrogi nous matti r
Fat
Water
Nitrogenous rnatttr
Fat
Carbohydrate
Ash
Water
u ad ('tab
Oystci
BCKl)
12 14
1917
1 17 1 14
76 ti 84 31
02
12
3 7
2 0
80 9
The coarseness of the muscle fibres m the
flesh of the lobster and ciab makes J.he limbs of
these animals veiy difficult of digestion Raw
oysters are easily digested, but of low nutritive
value owing to the high percentage of water.
The nature of the cailx>hydratc material v\hich
they contain is doubtful,
358
DIET
MILK AND ITS PRODUCTS —Cow's milk has the
following approximate composition • —
Water .
Proteid
Fat
Sugar
Mineral mattei
87 to 88 pei cent
2 to 3 „
3i to 4* „
4 to 5
07
It fluctuates bo gieatly in composition, faro over,
that one does not know within 30 pei cent how
much nourishment he is ordering in pre&ciibmg
a given quantity of milk to a patient daily Fat
is the most variable element of all, and IH usually
taken as the oiiteiion by which to judge milk
Good milk should contain I pei cent
The proteids of milk «ne casemogen and lact.il-
humm, theie being about one pait of the formei
to seven of: the latter in the milk oi the co\v
Caneinogen is a psuudo nuc leu.ilbumm. It yields
no unc acid bodies, and no su«>ai on hy (holy sis
This gi\es it a special \.ilue m gout «uul diabetes
Pure CRHciuogon is now piepaied in the form of
a flour (by the Piotene Co ), and used in the
preparation of diabetic bxeud and biscuits
"Nutiose" is ca&emogen icndeied soluble by
being combined with soda
The sugai of milk or lactose Ins the .id van-
tage of not being vny sweet It may thus be
added to milk and othoi liquids, r </ lemonade,
to increase then nutntivo value Such addition
is useful 111 the rase of patients \\ho aie suffbimi;
from acute disease and are unable to swallow
laige quantities of noinishment Ft is not
fermented by yeasts, and may thciefoio be of
no use in cases of dilated btoma( h, but is readily
changed into lactic acid by ccitain nnoio-
org.imsms, and in th.it foim is a coniinon cause
of diarihuM in infancy
The chief mineral mattei in milk is calcium,
one litre of it containing about a giammc ami
a half of lime Some of the calcium is combmi d
with utiic aoid, the icbt OCGIUH as phosphato
Milk contains veiy little iron, four 01 five pints
being lequned to yu-ld thr amount of non CIO
milligrammes) icqiuml daily
The germs \\lmh aie so apt to be contained
m rnilk can most easily bo killed by boiling
Vasteiuisatioii — which consists in keeping the
milk at a tempeiatme of 70° Cent for twenty
minutes— is sufficient to kill most disease germs,
but does not dostioy all spoics nor the lactic-
acid producing bacteiia It has the ad^antaoc
of not affecting the taste of the milk It may be
rained out by placing the milk in stop pei cd
bottles, and setting these in a deep sauce-
pan of watei heated to the necessary tempera-
tme
The digeitilihty of milk is interfered with by
the dense clot which it foims in the stomach
The density of the clot depends on (1) the
amount of the casein , (2) the degree of acidity
of the stomach contents , (3) the quantity of lime
salts present. All of these factors have their
influence lessened by dilution. Water may be
employed for the purpose, but barley-water or
lime-water is better. The former acts me-
chanically by entangling the pai tides of casein.
Lime-water seems to lu\e a specific power of
preventing clotting apait from its alkalinity
One part to two of milk is sufficient to ensuie A
loose clot.
A pint of taw milk remains about 3£ hours m
the stomach, sour or skimmed milk about ft
hours, and boiled milk about 4 houis.
Milk is not \eiy completely absoibcd When
it constitutes the solo diet only about 90 per
cent of its potential energy is leally a\ tillable
Thus it leaves a largei icsiduc in the intestine
than many othei foods (see Table, p. 355),
Cluldicu absoib it bettei than adults Iknlrd
milk is not '/n it <' so \\cll absoibod as law The
nutiitiu' value of milk is lnj»h, but about 0
pints of it would bo lequned daily by a man
doing modulate \\oik, { to 5 pints, ImwcM'i,
aie sufficient to maintain the nutiition of a suk
pei son lyim» in bed It contains too much
watei and too imuh pioteid and iat in piopoi-
tion to its uubohydiatc, and IN too expen-
sive to justify one in ie»aidni£ it as a pciiett
food
Cttfini contains ielati\ely nnuh untie iat than
milk, but the actual amount vano-a t»ieatly from
12 oi 15 pei tent in oidmaiy eicam, up to JO
per cent 01 mou- in thick 01 sepaiated cie.mi
It contains as much sui;ai and pioteid as a
siiiiil.ii quantity of milk
liutter ha^ about *0 pel cent of tat and a
small amount of piotud, the loniamdoi being
watci MtiiiMiino, winch is made fiom the
nun c oil} con-tituents ol animal fat, has almost
the same chemical composition, and is piactically
pqu.il to buttei m nutntjve v.due
AW/W//SS is pioduccd fiom male's milk b\ a
combined lactic and vinous h i mentation
Kefkit is a -similar pioduct pn paitd fiom tlie
milk of the cow In both the casemogcn is
thiown down in <i ftnelv flocculcnt, «ind thciefoie
easily digested, foi m, and is also pai tly peptomsed ,
most of the sugai is coin cited into lactic acid,
and a small amount of alcohol and i Uigo pio-
portion of carbonic mid gas piodi »\ Thioe
and a half (juaits (a daily allowance) of koumiss
yield 140 gms of pioteid, 80 of lat, and 140 o,"
sugai , w ith a combined fuel value of 1 9 1 8 Calorics
These preparations present milk m its most easil j
digested form, and owing to the destiuction of
much of the lactose, aie bettei in some ca&eb of
diabetes than oidmaiy milk
Cheese consists of the casein and fat of milk,
modified by the growth in it ot various micio-
orgamt»ns, to the bye-products produced by
which the different varieties of cheese owe their
distinctive flavoui. The composition of the
common cheeses is shown in the following
table —
DIET
359
COMPOSITION OF
Cheese
Water
1
| Protcul
tut AMi
AuiagpCrrnt
Heal Cost ol
lib
per Ih
Xutimient
._ _
",
s d
8 ll
American
269
' <29
31 4 5
0 0
0 S£
Camembeit
486
21 0 , 21 7 44
7(1 each
1 ij
Cheddai
31 <»
'W 4 , 26 8 i 9
0 S)}
1 2
Chi'shm
352
20 4 30 7 4 5
o 94
1 2
Cteani
V20
, 86
/> 9 15
Dutch
,J29
308
17 « 63
0 7
0 10$
Gloucustii
31 9
i ,367
247 44
0 9^
1 2
<.»orgoi)/ol i
,102
, 259
260 47
0 <J
1 3
Umy/it1
-54 ]
315
28 2 40
0 10
1 i
Riiiiiusiin
300
438
16 5 "i 0
o iij
1 M
Ronnotoit
211
34 8 31 3 1 5 ri
1 1?
1 ••
Stilton
276
23 9 .38 9 i 3 1
1 2
i 1 7
is very complete, only about 5
per cent of lesidue being left
Hence eggs may bo safely
ordeied in duithuu
The nutritive value of one
egg is equal trt that of about
half a, tumblerful of milk
The potential energy yielded
amounts to 70 Calories Tw ent>
eggs me i eq aired to supply
the amount 01 proteid icquired
daily
1 Those fignri -. HTU const nutnl bj tvknigthi iveraf.cs of tlu a ul)^
1»> lV,uiu.iui and Moor Pnccs au those ot the stoit*
Cheese is a condensed and cheap foim of annual
food of high nutnti\e value, and speciall)
idapted to supplement deficiency of piotcid in
the diet Its density and richness in fat, how-
e\ci, lendei it difficult of digestion This
difficulty is best en 01 tome by dissolving the
thcoM.1 and then mixing it with some cereal
tood, tq macaiom Solution can easily be
bi ought about by adding to eveij quartei
pound of the gialed cheese as much bicaibonate
of potash as will he on a thieepenir) piece, and
stilling the whole with a little waim \\atei 01
milk The absoiption of cheese in the intestine
is fully equal to that ot meat
Keats — An oidm.ii> hen's egg weighs about
2 ounces, oi which about 12 pei tent consists ot
shell, .18 pei cent of w lute, and 30 per cc nt of j oik
The shell consists of t aibonate ot lime The w lute
and y>lk have the following composition —
Wat«r FinUiil (at Ash
AMnlc 817 126 02r> 0 50
^olk . 000 16 2 11 7r> 1 09
The white consists if a solution oi vanous
pioteids, tho chiei o which is egg albumen
Some, at least, of these yield a reducing sugai
on hydiolysis
The yolk contains a laige amount of emulsified
fat and a considerable piopoition of lecithin It
contains also othei oiganic compounds of phos-
p\ rus, amongst them a nucleo-pioteid and an
oi game compound of non Indeed, jolk ol egg
is one of the nchest food SOUKCS of non that we
possess The fat t that it contains so much fat
and organic phosphoins seems to make yolk of
egg of peculiar use to growing animals, and
explains its value in the diet of child ion
Experiments on their digestibility have shown
that two lightly-boiled eggs icmam in the stomach
about 1J houis If taken raw they remain
lather longci, and law eggs are not really moie
digestible than those which have been lightly
cooked. Hard-boiled eggs remain about tluce
hours. Tho absorption of eggs in the intestine
FOODS
The vegetable foods aie dis-
tinguished from animal foods
mainly by containing much
more cai boh y d i ate and consider-
ably less pioteid The caibo-
hjcliat( is chiefly in the f >im ot
stuch ,i I though some \egetable ioods, e </ finite,
t uiitd m sug,»i iiihli A(l The pioteids met with
belong mo*-tl} to the globulin class, and contain
less caibon and moie mtiogen than animal pro-
teids, w hich is said to gi\e them a lowei nutntive
\alue The comparati\e poveity of vegetable
foods in proteid renders it difficult to obtain a
sufficient supply of mtiogen fioin them alone
unless a laige quantity is eaten, and the con-
sumption ot \egetable foods in quantity is in-
convenient owing to then bulk This bulkmess
is due to the fact that most \egetable foods
contain much cellulose ami mm h water, foi
oven tho dry vegetable foods, eg tho cereals
and pulses, take up much watei in pioccss of
benii> cooked Hence the pine \egetanan has
to choose between living on a minimum of pio-
teid or consuming such a bulk ot food as thrown
a coiibideiable stiam on the stomach and bow eh
The adoption oi the f turner altei native seems to
diminish one's eneigy, as distinct fiom muscular
stiength, and to lowoi one's powei of resistance
to disease , while tho latter course is apt to
culminate) m disoideis of digestion The dis-
.uhantagcs of a puioly vegetable diet are in-
creased by the inability of the intestines to
absoib Lugo quantities of vegetable piotcid, as
tiheady pointed out, unless piesented in \eiy
special foims On tho other hand, then com-
paiatnc poveity in mtiogen adapts the \egetable
foods foi use in chionic icnal disease and in
gout, while then bulkmess is of value in habitual
constipation by stimulating penstalsis, and m
obesity by aftoiding a maximum of quantity
with a minimum of nutntive material
The \egetable foods may be divided into the
following classes —
1 Ceieah — The composition of the
genei.illy used of these is as follow* —
360
DIET
COMPOSITION OF CEREALS 1
of which they may contain as much as 9 per
cent
f \ 4 1 —!
Biscuits, being almost free fiom water, are
1 3
<g
£?' 1
£§
more nomishing than bread, three pounds of
£
a!, |
II
the former being equal to five pounds of the
120 110
10 0 10 0
fill HO
17
45
SI
<c I y
10
35
21
latter They are also very easily digested
Semolina is prepared from the central paits
of hard wheat It contains 106 pei cent
Wheal
Oato
„ (hulled)
71 2 1 22
5l'l , 120
6Sd i 13
liarley
12 i 10 1
1 0
«01 i 3S
24
piotcid
11 0 10 2
2 3
72 J ' 21
2 1
Maw
18 S P 7
r»4
OS o 20
15
Macainni and wtnucelli, which aie prepared
Rice (unhnlli d)
10 A to 8
120 72
1 0
20
OS 1 00
768 10
40
10
from good wheat floui by mixing into dough
" (rniisiM d)
Millet
Jlwkwhiat
124 60
121 lot
1 1 0 10 2
04
22
7l> 1 ! 04
us 3 20
613 111
03 '
22
22
and then diying, have a smnlai composition
Hominy consists of split mai/e and resembles
l
the lattei 111 its constituents, but has only A per
1 Tlie t\bln lepresenti the lompositmn ot the ic-Pils in thru
ciude loim Ihe tiKims nn i ompilul hum i vist niimlNi ot
•innlysos. the d ita ront.uni d in thi leimrt on the composition ot
cent of fat Curnflotn consists of practically
pure st.udi prepaied from mai/e
tho CPienls e\hihitid at tin Colmnbiin
ni.d(US Hull 45) Tin inntiul Ins
K\|iobiliuii luing fttih
inn i ill ill ited fiom tin
2 The J'ulsei have the following composi-
nitroKon, IIMIU th«i ftutor *i 7 tor nil t\<ipt buM, mu/e, and
tion --
Inn k»hi it, whoie the 1 u tui 6 u is "inploji d
CoMPOhlllDN 01 PlTlHFh
COMPOSITION- OP VRonuns DFRIXBD FROM
C* HE u*s
(Fiow the Mian\ nf many Awilytet)
g
1
*:
i_"l
ii
L * ^ _' " :i
$•?<
£
dii on IV is
/Sl' to1 lii 0 (1 rj 0 **
(Ml
l>iud ,
13 O1 21 0 Vt 4 1 s ' d 0
WhintMial
2 1
12 'I
i'»
70 1 0
12
Ijentils
1 1 7 2 ' 2 r«S 1 J 0 ' J 0
j> 7
1 Fine Wheat I lour
< 0
«i i
OS
7r» 0 7
07
llnise lit ails (dt\)
1 3 1 _"» i 10 •) 1 7 i 1 "5
• ii
A 3
< Oatnioal
72
142
7 J
•>5 | J 5
1 <i i
liioad 01 \\uidsoi
RollidOnts
Bailej M..U
111(1
72
22
til ' J rt
71 1 S
2v!
Himch lie ins (Hill
s 4 20 4 r>s o 201 0
l
3.,
Ptail Hailev
Co u si RM Flour
Finest
CoinM.nl
M (flue)
Hue kn heat Fiom
7
1
2
1
0
40
7 1
14 J
fi S
7 1
1 2
21
0 ')
4 d
1 )
1 2
7n ' 0 s
f.rt 23
SO OS
72 1 1
7S (is
7> 06
T 2
22
IJ'
00
12 ,
cots \eits)
ri,imots(H Hhnrs)
(cookeil)
Sr u lit Runnel H
so 5, 1 5 71 u 1 oo
11 7 2*0 '•• s 23 10
7H 0 41 20 s 0 1
(miUillu I
o 7
12
07
Hi/In. (Hikidiin)
117
7 '•
04
(stewed) .
nl 12 17 17 o j' jq
03
So> lit ins
11 0 12') 2S7 Is 1 4 4
l'i
„ liem HOU!
«M W i 2s 2 M 7 ' 4 0
•iS
f\e *i
Pea NuN
-3 210 170 4» 1 I >
1 0
maize in America, and nee in the East Maize
is Hiiperioi to wheat in fatty uiatenal, while rice
is characterised by its small proportion of both
proteid and fat Oats aic about equal to mai/e
m fat, and superior to wheat in proteid, and r.uik
as the most nutritive of all cereals A plateful
of porndge is equal m nutritive value to three
slices of bread The chief pioduct of wheat is,
of com so, bread The following is the aveiage
composition of white and whole meal bread
respectively —
Water
Proteid
Fat .
Carbohydiates
Mmcial matter
White Wholemeal
39 45
65 63
1 12
51 5 45 3
1 1 2
Tho gi eater moistness of whole meal bread
causes it to bo haidly at all superior to white
bread chemically, while physiologically it is
iound to be not so well absorbed Tt is there-
fore on no account to be preferred to white
bread for ordinary use, though it is of value in
cases of constipation On the other hand, breads
such as Hovis, which contain a large proportion
of wheat genii, are peculiarly rich m proteid,
They arc richei in mtiotrin than any othei
u'getable foods This they owe to the piesence
of a vegetable pioteid called legumin or \ege-
table casein Legumin ioims insoluble com-
pounds with lime salts, whuh is the explanation
of the advantage of < ookmg the pulses in soft
\\atci
The pulses are somewhat difficult of digestion
in the stomach, and aie apt to produce a feeling
of lepletion, even in small amounts In the
intestine they aie pi one to excite flatulence
owing to their iichness m sulphui Lentils
have least tendency in this direction As ,i
group the pulses are wel1 absoibed pnmded
they be given in a state of tine division
Soy beans and pea-nuts arc largely used m
the prepaiation of diabetic foods owing to their
poverty in carbohydrates Tho preparation
Kevalenta Arabica consists mainly of Egyptian
lentil flour
3 Tho roots and tvber* consist chiefly of
starch, as the following table shows —
DIET
361
COMPOSITION OF ROOTS AND TUBERS
Wntei
I
. iiit iMbii1
"|
Asli
Ext mi
tms
Potatoes
767
12 1 19 1
01 06
09
1 1
,, (1 »oi ltd in bkm)
738
i
Cdi rots
85
0 5 , 10 1
0 3 1 5
0 0
1 0
„ (looked)
934
053 ' 339
017 18
014
Tiiini|is
90 , 1 09 1 50
0 1 .1 18
08
1 1
„ (looked)
Radishes
97 L"i , 0 32 ' 0 bfi
90 8 1 4 46
0 0»» 12
0 I
032
07
Hoet loots
839 i 05 11 u1 0 1 Ul
09
1 0
(cooked) .
94 8 0 44 ' 2 b3 0 i)B 1 3
03
Pat snips
801
11 11 J 1 0 21
1 3
(cooki-il)
0728
0 22 , 1 t(. 0 29 0 72
0 12
Aitit hokrs . .
798
23 14 ,'• 03 2 u i 1 0
„ (cooked)
91 6
1 h 4 ft
0 OS 09 |0 t.l
Onions
89 1
16 ' 63,03 20 iOO
Sweet Potatoes
72 9 i 16 2*2 5 : 0 -, 1 S ' 0 7
Yams
70 6 i '22 lr» 3 r -» ii 'i i 1 ,
1 1 9 I'l r cent ot sag a
Of Hie small .amount of nitio^riioiih nuteiial
which they do contain <i laif-e proportion is in
tho form of niniilo bodies of little 01 no nutritive
value Hence th»>y arc too pooi both in pioteid
and in f»it to bo fitted to constitute the main
pai t of any diet
It is \\oith icmt>inhciiii{> th.it potatoes ion
tain considerably less sUuch than In cad, and
may consequently be allowed m largei piopoi-
tion than the lattci to dises of mild diabetes
Tapioca, sa</o, and
ti i roivruttf arc all piepaia-
tions ( untaining ,i\>out
88 pel cent of staich, and
piuctically in» nitrogen
Alone they aio of limited
nutntive value, but aie
useful additions to foods,
uub A*- milk, which .ue
i if her in pioteid The\
lank amongst the most
completely absorbed ot
.ill ioorlf, Avhich justifies
then employ nient in cases
of cluml'aa
4 Green tvr/cfrrftfrs aie
oi \ei\ lo\\ nutntive
•value, ,is is borne out
by tin1 following table
lepi sontiMg the i com-
position
They o,»*c then thief impoiUnte as rpgulai
.u titles of diet to the .ilkalmo salts, especially
of potash, which the} ( on tain These aie e\-
eietid in the foim of c.ul)oiutes in the urine,
and for that reason ^recn ve«jjet.ibles should be
ficely consumed bj patients \\ith i tendency to
i>iavel Their iichness m ti*llul(ist> m.ikes them
difhtult of digestion, but iisctul as supplying
"intestinal ballast" in eases of constipation
They contain so little taibohydiate that thev
01 YhdM MtLKS
Nitin
..t nous
1 it
i
Kiwi \ ilui'
Mittn l
lmhnt.s Mittu |
pc i 11) |
raN
Cabbage
89 6
1 8
0 i
58 13
1 1
Ib5
„ "* (cooked) 0? 4
06
0 1
01 { 0 13 ! 13
Cauliflower (brad)
907
22
04
17 OS
1 2
17 •>
Soi Kale
033
1 4
38
06
0 9
(looked)
9795
0 4
007
03
02
1 1
Spin K h
906
'25
05
38
1 7
00
120
\igeUblfAIauo\v 018
06
0 2
20
05
1 3
(cooked) ! 09 17
000
004
02
005
037
Biusscls S pi outs
937
1 5
01
34
1 3
05
Tomatoes
91 9
1 3
02
50
07
1 1
10r>
(cooked)
0407
1 0
02
0 1
07b
1 5
(iirons
829
38
09
8 9
35
275
Li'ttuce
94 1
1 1
0 4
2b
10
0 "j
105
„ (rooked)
972
Oo
0 16
05
0 t
0 0
Leeks
01 8
1 2
05
5S
07
150
Cek-iy
934
14
01
33
0 9
0 9
85
„ (c-ookcd)
070
03
006
08
05
1 0
Tin n ip Cabbage
871
26
02
71
1 5
1 3
145
Khubaib
046
07
07
23
06
1 1
105
Maccdome (tinned)
931
1 4
45
1 0
110
Watei cress
931
07
05
37
1 3
07
Cucunibei
959
08
0 1
21
04
05
70
„ (rooked)
974
05
002
07
02
0 9
Aspaiagiib
Salsify (cooked)
917
872
22
1 2
02
008
29
90
09
03
2 1
22
110
Endives
04 0
1 0
30
08
06
Savoys
Ked Cabbage .
870
900
33
1 8
07
0 10
60
5H
1 6
0 7
1 2
1 2
Sanerkiftut .
863
15
0 8
4 4
70
Probably only about a hall of the mtiogenous mailer ionsists of proteul.
362
DIET
may be used, with very few exceptions, even 111
severe case* of diabetes Cauliflowers, being
more easily digested than any other form of
They may be conveniently divided into
" flavour fruits " and " food finite " The former
include all the berry class, and are chiefly eaten
COMPOSING^ OP
\VutPi
Proteul
Kthn
, Extinct
Carbo-
hjiiratos
Ash
Cellulose
tCUlH
Apples
8'2 "i
04
1 05
125 04
27
10
, (diied)
.to 2
1 4
1 30
57 b
18
Pears
839 ,
04
(
16
11 *5
04
31
0 1
Apricots
850
1 1
t
134
05
Peaches
888
05
02
58 06
3 1
07
t!i tonga "vs
808 ,
04
14 4 03
4 1
Plums
784
1 0
i
201 05
9
>
'
(and Cellu
lose)
Xei t irmes
829
06
i
15 ') 06
Cheuu's
81 0
08
08
100 06
38
Goosobemes
860
04
89
05 27
15
Currants (icd, black
ipd
i
white)
852
04
1
7 9
05 , 4b
1 1
Stiawboiries
891
1 0
)5
6 J 07 22
Whoitlebunes ( -
Blae-
(
bou IPS or Bilberries)
82 1
07
30
13 "> 0 4 |
Blackbemes
889
09
J
21
1 75 ' 06 j
Kaspbcriies
858
1 0
i 126 06 1
Cianbcmts
88 -.
0 ri
07
1 101 ,02
t i
!
1
Grapes
7^0
1 0
1 0
. 160 ,05 25
Melons
898
07
0 1
86 Ob
Watei Melons
929
03
01
65 02
i
Bananas
710
1 5
o r
22 9 09 02
! Oianges
SG 7
09
97
06 1 -,
small
' quantities
Lemons
893
10
09
83 05
1
Pmciipplvs
893
0 1
0 J
97 03
J
1
1
Dates (ilnoil)
•208
4 4
2 1
65 7 1 r» *» r>
Fii^» (diiid)
200
55
09
04 0 2 J ' 75
„ (fresh)
791
1 5
188 ' 06
Pi lines (dnetl)
'26 1
24
08
08 9 15
i
,, (fush)
802
08
'
18 5 0 5 I
1
Cnn mtb (diicd)
27 «»
1 2
30
1 65 7 22
Raisins
140
2T.
47
747 41
Coni])osition oi edible pai ts alone
ropresu
nteil
Where cellulose is not gi\cn it is i
ndudcil uith
c ubohydiates
COMPOHITIOX OP NUI*»
for the bako of then
aupccahlf flavour Like
1
\\ iter
PiMeul
(Ml
C.nbu
hy.lt ilt s
fVlllllOM
Vfimral
tho green vegetables,
hmu'vci, they are als»o ot
Chestnuts (fresh)
(dried)
385
58
66
101
80
100
452
71 4
17
27
vegetable salts of potash
\khichtheycontain The
Walnuts (fiesh)
44 :>
120
31 b
9
1
08
17
"food fiuits" «uo icpie-
(dned)
Filberts and Ha/els (fiesh)
„ (dried)
Sweet Almonds
1 6
480
17
60
156
80
149
24 0
62 b
285
664
51 0
7 1
11 5
97
100
78
32
30
20
1 5
18
3 0
scnted by the nq, banana,
date, and other diied
fiuits They contain a
' Pistacio Keinols
Cocoa Nut (fleshy part)
„ „ (diied)
, „ „ (nulk) .
74
166
3 5
903'
217
52
60
05
51 1
.15 9
674
140 25
84 29
318
90
33
10
13
laige propoitum of cai bo-
hydrate in tho fonn
of sugar, which gives
them a quite consider-
- -e
" " " ~ able nutritive value, and
vegetable, may be advantageously recommended
to the dyspeptic
are used in many countiies, ey Egypt, in
place of the cereals. It should bo remembered
5. Tho//?uta form a large class, whose com-
position is appioximately as shown in above table
that the chief sugar met \iith in fiuits is
leevuloao, and that the latter is bcttei utilised
DTKT
363
by diabetics than any other form of carbo-
hyrhatc
The nuts form a class by themselves, and arc
characterised by great richness in fat, as tho
pi cceding table show s Their richness in iat and
cellulose, and the compactness of their sti ucture,
render them difficult of digestion Being com-
paratively poor in carbohydiates they arc laigcly
used in the manufacture of diabetic foods
6 The fungi, lichen*, and nlt/tr aie a small
and unimportant group of vegetable foods The
mst-mcntioncd aie represented by the mush-
loom and truffle, which have the following
composition —
Miihlnooni 'liulH'
Watei 93 7 TA 0
Piotrul 22 61
Fat 0-5 06
(Jdrbohjiliitr 12 102
Cellulose 11 64
Ash 0 '! 20
These aie voi} indigestible in the stomach —
so much so, indeed, that the symptoms ot
indigestion which they arc apt to pioduce hu\c
often been mistaken foi poisoning They are
also veiv imperk'ctly absoibed, and cannot rank
as foods of ,1113 value Tho alga; aie repie-
sented by lush, and the lichens In Iceland
moss These have the following constituents
(Church) —
lush Moss T« 1 mil Moss
AVatfi Ib 8 10 0
PintPid 91 87
Mm ilaip ">r> 4 70 0
(Vllulosi 2 2 * ft
Ash 14 2 1 5
The " mucilage " consists mainly of lichemn
- a cai boh} di ate containing mateiial of doubt-
ful natuie It (eitainh \ields a leducmg
sui>ai on h \diol\sis The nutiitive \aluc oi
these substaiues is \ei) low, foi a teaeupful oi
good Insli moss jelly contains only about a
shilling's weight of solid mattoi Decoctions of
them make pleasant demulcent dunks, but that
is tho limit of then usefulness in the sick-
100111
MINIUM f1(>NsniLKMs or Foor> — \bout 5
pei cent of the body weight consists of ash
MiiuM.il matters aie therefoie to be legaided as
tissue buildeis, and as such are essential to life,
and as a mattei of fact it is found that death
ensues in a few \\eeks il no moiganic mateiial s
aie supplied m the food The chief mincial
matteis lequncd are sodium an<t potassium,
calcium and magnesium, iron, phosphoius, sul-
phui, chlorine, xnd traces of such substances as
manganese and silica
It is impossible to say exactly how much of
any or all of these is icquiied daily, foi the
reason, amongst othcis, that seveial of the
mineial ingiedicnts of the bod} aie exacted by
the large intestine, and one can, theiefoic, uevei
distinguish those moiganic constituents of the
fiuces which ha\c simply not been absoibed
from those which have been absoibed and again
excreted An oidnmry mixed diet, howcvei,
contains about 20 grammes of mineial matter,
and that may safely be icgaided as moio than
a sufficient supply Fuithei, it niav be asseited
that we know of no disease ninth ih pioduccd
by an excess of mineial ingredients in the food,
and of almost none, with the exception, perhaps
of scuivy, which is due to their deficiency
I'ota^ium is most abundantly icpiesentcd in
\egetab1e, and sc*fr?//// in animal foods Tho
foods i idlest in (tine are milk, eggs, cereals, and
a tew vegetables, such AH radishes, aspaiagus,
and spinach Meat, fiuits, and potatoes aie
poor in limp It has, theiefoie, been ictom-
rnondcd th.it one should foi bid the former class
and 01 dei the latter to patients who arc suffei-
ing fiom athoioma The utility of such a pio-
ceedmg is, howe\ei, very doubtful
About 10 milligiammt s of it on arc contained
in an oidmaiy mixed diet (Stockman) The
foods nchest in that metal aie jolk of egg,
potatoes, hi cad, oatmeal, and nee Milk is one
of the pooiest of all foods in mm, but fr\e pints
of it contain the leqmsite 10 milligrammes.
The (ompaiati\ely small amount of non con-
tained in oidmaiy food lendeis it impossible to
look to dietetic means alone as avoiding a
sufficient method of ti eating amentia*?
Fhnyi/mm'* seems to be of special \alue in
aiding the foimation ol new tissues It is piob-
able, ho\\c\ci, that if it is to be .ivailable foi
that pin pose it must be supplied in oigamc
combination, and not sun pi} as moigamc
phosphates The >olk of cgj; and tissues rich
in nueleins, < i/ the loe of fish, sweet hi cads,
etc, aie the iidiest soui<es of oig-imc phot-
phoius The impoitancc of jihosphorus as a
In am food is piobably ovcuatcd
Xutji/nn is almost wholly taken into the
body in the foim of piotcids, little 01 no in
oi<iamc sulphui being contained in an oidmaij
diet
('/if fit mi is laigeh consumed in the foim ot
common salt, of which about 10 grammes aie
usually added to the diet in addition to that
which oidmaiy foods alieady contain That
the actual addition of salt to the diet is un-
necessaiy is pimud by the expenence of those
who live without it altogether On tho othei
hand, (he c\il effects attiihuted to its use aio
entirely imngin.uv It is an undoubted aid to
digestion, and, pioMded enough \\atei be sup-
plied as well, tends to limit i.ithei than increase
tissue A\aste
HEN EHAI.BS
The use of alcoholic beverages has been
discussed imdci " Alcohol ' We may therefoie
confine ouisehes hcic to the consideiation of
watei and the alkaliwdal be \erages (tea, coffee,
and cocoa)
Watti makes up about two-thuds of the
364
DIET
body. Like the mineral matteis, it is thus an
important tissue -builder and essential to life,
death resulting in a few days if it bo cut off
About 2^ pints of water should be consumed
daily m addition to that aheady contained in
ordinary solid food Obviously, however, this
quantity will vary greatly with" such conditions
as tenipeiatutc and woik Tt is almost im-
possible, by the free drinking of water, to
increase the amount of it m the blood, uoi can
one, by limiting the supply of watei, leudci the
blood appreciably pooiei in it On the other
hand, it scorns " pi obable that the habitual
ingestion of an excess of fluid mav, ultimately
pioduce a moie watery condition of the tissues,
and if those bo aheady watci -loaned a diminu-
tion of fluids in the diet may canst* the passage
of watei fiom them back into the blood This
may explain the favomablc Jesuits sometimes
obtained by limiting the supply ot fluids in
caidiac diopsy
Water M not absoibed in the itomach, but
loaves it — if half a pint be taken — in the
com so of about half an horn Even large
quantities of watei do not appieciably delay
the digestion of tood in the stomach, while in
the intestine it piohahly aids somewhat the
process ot absorption The upid pasture of
watei thiough the stomach makes it a pecuhaily
dangerous vehicle of disease If the souicc of
the watei be nt all suspicious, theiefore, it is
best to boil it, and le-aeiatc it in a gazogene,
for no filtei is leally tellable toi domestic use
AVatei does not incie«ise tissue waste, but
meicly washes out the waste pioducts Foi
this leason its free use in uout, renal disease,
and diabetes should be eiicomaged, and caic
should be taken to see that the patient gets
enough of it m fevers, and if the pyloius is
obstiucted a due piovision of \\atei should be
ensuied by the use of saline enemata Other-
wise thoie is daunei of the supeivention of
toxic symptoms fiom the letention of v\astt
pioducts
Aetnteil uwtet s aie more fa\ouiiible to digestion
than 01 di nary watei, foi the caibomc acid gas
which they contain acts as a stimulant to the
btoinach This gas is lapidly absoibed thiough
the stomach wall, hence it is well to a\oid
aerated waters in marked cyanosis They
should also be foi bidden to patients in whom
sudden distension ot the stomach may be
dangerous, e y cases of gastiic ulcei or caidiac
embarrassment
TK\, Coi i UK, AM» COCOA — Ten contains the
alkaloid theme, along with some volatile oil,
tanmc acid, gummy matteis, etc Indian and
Ceylon teas are richei m all the former in-
gredients than £hma teas, and gtecn tea is
richer than black An ordinary teacupful of
tea infused foi five minutes will contain at
least one gram of tanmc acid and one or two
grains of theme The longer the tea is infused
— up to about half an hour — the more tanmc
acid will it contain If one wishes to minimise
the amount of tanmc acid, one should use China,
tea and infuse it for foui minutes only The
addition of milk also aids by pi ecipitating the
tanmc acid
Cofee contains caffeine (which is identical
with theme), tanmc acid, and .111 oily substance
called cafteol, besides othei lesh impoit.mt m-
giodients A teacupful of black coflee has
about the same amount of caffeine and tanmc
acid as a siuulai quantity of tea " French "
coffee consists usually to a laigo extent of
toasted tlueoiy, the chief ingiedieut of which is
caiamel
Cfxtm contains the alkaloid thcobiomme, but
in small amount , it is closely allied to caffeine
in addition it has (in its oidmaiy dietetic form)
about 26 pel cent of fat, 1J pel cent of proteid,
and 23 pel cent 01 so oi caiboh)di,ites, besides
a considerable quantity of ash (about 4 per
cent)
All of these be vciageshavcai etai ding influent o
upon digestion, the eftect of tea being gioatc-st
Coffee is apt to nutate the stomach by its
cafteol , it should theiefoie be foi bidden in
cases of gastnc catanh Cocoa has least in
flueiice on the digestion of othei lo.uls, but the
large amount ot fat which it contains is apt In
make it chs»agiee
The only membei of the gioup which h,isan>
clonus to be leu.uclcd as a locxl is cocoa See-
um, lurauvei, that only about 10 grammes ot
cocoa aie used to make a bicakfast cupful oi
the beveia«;p it cannot senoiislv aid in general
uututiou Indeed, seventy -five such cups
would be tunnied to supply the amount of
potential eneig) lequued daily
Tea and coffee aie chiefly useful in vntue ot
the caftcme and \olatile oil which they contain
These act as stimulants to the nei \ous system,
tind to some extent to the heait also, removing
the sense ot fatigue and mci easing leflex at tion
The fact that they aie usually taken hot no
dt)ubt contributes l.ugely to then stimulating
effects The effects of tea and c offee on genoial
metabolism is m the direction of increasing
lather than of retarding body-waste
These beverages are useful in neivous ex-
haustion and in alcoholic coma, they might also
be used moie laigely than they are m fevei
On the othei hand, they should be avoided 01
used \vith great moderation by "neivous"
people, and by those sutteiing from sleeplessness
or palpitation Then effects on digestion somc-
! times render it necessary to foibid their use in
dyspepsia, although it is probable that the
digestive disturbance attributed to the use of
these beverages has been greatly cxaggeiated
[Should the tecent work by Chitteuden
(Phynologtciil Economy of Nvtt ition, New York,
1 904) bo substantiated by other observers, our
present conceptions of dietary standards will
DIET
365
need icconsidcration His observations, made
on athletes, volunteers1, and professional men,
tend to show tliat health and efficiency are com-
patible uith a diot containing much less than
the accepted minimum of proteid They ex-
tended o\ei sovoial months, dining \\hich con-
sideiable miiRculax \ioik was done by the j
subjects \\ithout impairment of health or |
vigmn, nor did tho eneigy value oi the diet ,
requite mt lease (Jhittenden's conclusion, that j
"tho amount of pioteul food ncoded daily for \
the .ictual pltyMoIogu.il wants of the body is j
not moie than one half that oidmarily con- '
siuiied,'1 h,is iiot as )ct lound genual acqui-
escence, 1101 aie independent mateiials foi
foiimmr a judgment as to its coiiectncss as yet (
n\iiil.il)Iof but his results are so no\cl, and ha\e
attiacted so much mteiest, that it is only light
to dia\\ attention to them hcie ]
Dietary- — An allowance or i emulation of
iood, such as is sot down as tho nilo in hospitals,
\\oikhouses, sdmoK, 01 ,is>lmiis, 01 a umibC oi
diot, Mich as is xccoinmundofl in illnesses »SW
DILI
DietetiCS. - -The science \\hidi deals \\ith
ihe ici;ul.Lt ion of the amount .mil chaiactei of
to(Ml in health and disease Mf DIPT , Pmsio-
1IM.Y, FOOD AM> Dl<jl"»l10N (Dllt(ttt<>)
Diethyl. - An isomeiie toim (V2\lr, (MI-,)
ol iioiiu.il butane (<14Hlo) it is iound in
peti oleum
Diethyl am inc.- Ainiuoma m \\huh
t\vo i if the h\dio»cn atoms ha\e been leplaced
bv ethyl xailuV (l\,IIr> C.H, HN 01 NHEt,)
Dietl'S Crises. — The sudden attacks
of abdonmiil pun, auompamed bj nausea,
umiitmjj,, and collapse, which oceui in cases oi
Hoatum kidue}, and aie piobably due to
stimulation oi tho kidney 01 to kinks in the
icnal u-ssels iS'if ('RIMS
Dieulafoy's Aspirator. ,S^AM>IK\-
TOH, USES OF
Jfotjj/iolo</tcal < han<j< 9 tlw < ny sett etion
Variation* in strictim* .
PIOKSIION-
Conijuo,ntio?i of ijn*tn< june
Conditions injluntetin/ t/te t>enttion
/S'ow7ces and mode ft toiinniirm of ton-
367
.567
367
367
"56S
j\n rtnn j
Motor medians m
Duration ot Junction
FLN< UONS oi HIE (Jvsiim .Iui< * AM) I'uo-
mic !•• 01 iis A( in IN
Condition afjuttny ifijmltti/o/ jiijitun-
ivaftvn
Actitui, of ot/tti tti tfinib
Kraininalitm of- ti<t\t)i touting a/to
Diffusion. *SVe
(Intcn/tniK/f of <ra<«"* in the Lvny\ aiul in tin.
7'z»si«s)
DE^alliC Acid.— Digalhc 01 tanmc acid
(CWH10O0 2H20) is an astrmgent acid found
maikeclly in "j;.ills and also in the tissues oi
many plautw >SVc GALLH , TANVIO ACID.
Digestion and Metabolism.
INTBOUUCIIUN
SALIVARY DK.ESIIOV
SALIVA —
Composition,
Phystoloyual action
Pathological constituents
305
366
366
366
366
Etnmimitnni <>i vtnutttil i
Eitiiiiiniitmn f>t .mjtnt
Patltoloijical
ni Junction
'
ot wtftivn
Motlc of ojtiftn of ttjn^titiuHt*
l'at/tnlt*/mtf altitaftoH*
'HEMlC S?( KKI1ON
+\atuii am? tutthotl of w-iettoti
J\r»fOMs metlumtvH
Action of the UI~I/MI -
J'ntholoynal r<nmtioit\
SIINAI SXIUHON
AMI Si Hsl ijUFVI FA IE OF
3ol)
370
370
370
37 »)
37o
375
375
376
370
377
377
377
377
378
$70
37U
380
(ju ) Fat* 3SJ
AltSOKPIlUN 01 PlJIRTllAl 11UN I'lt'jnLt Is 3S2
IMJSMXAI MO\EMEM>. 3S2
F i CES 3H.J
DEI K \'jioN 383
/•itf ffAo AlctuxoL (.Sy>M/f// Phy*ioloijy, Dt</rt>-
ttoti) , TUi N&oLOdY ((wtnnal /lnhieo-The)«peutics,
l)it/c\fn'c /)f«f^f/ris) (1riv\TE (General Charac-
ttlHttiS, I)n/?\tf<Ul) , HEAl)VCHF(CrtMS€S, Duffittlie
Tia<t) , KIDNL^ Srnf.ri'vrj AripmoNs 01- (Mov-
aMr Knhuyt Symjittaiuitnloyy, fr'aotto-Jntettina?
tfymjttom*) , LEuro(f\iosis (Dinui</ Diyntiori) ,
PittMoiot.i, FOOD AND Dn.bsiKjN , STOMACH AND
DUODPNTAI, DIM. \si<sor(^/<A^o/» m tin Stomach
and I) writ HHIH)
the vaj;ue tenn dij«estion all those
may he included to \\lucli the food
Mibstames are subjected, and the icsultant
changes which the \anous food constituents
undeigo in oidei to piepaie them ioi assimila-
tion by the tissues It theieioie includes a
manifold sencs ot processes alv tending to \vards
the same point, namely, the tiausformatioii of
substances, which in then oiigmal state could
not be made use ot by the cell, into pabulum
uhich can easily be taken up, assimilated, and
366
DIGESTION AND MKTABOUSM
used for the nutrition of the tissues The most
marked alterations which the food undergoes
aie brought about \y becietions which special
glands elaborate, the action being an extia-
cellular one, and earned out mainly bj the
action ot en/ymcs These non-li \mg feunents
have bpeuific actions on one 01 other of the food
constituents But then- IN an mti.uollul.ir as
well as an cxtiacellulai digestion, \\heie the
changes which the assimilated nuteiml undei-
goes c.in only take place in the In ing cell Oui
knowledge of those mtiacellulai changes is
still very limited, and in the \ast majonty of
cases we can at most vi\ that certain constitu-
ents oi the blood -plaMiia aie taken up by a
ceitam gioup of cells, and that they lea\e it m
othei foims of eombmation (v# "Bloml")
Most of oiu knowledge ot such processes has
been domed lioin the hfetolngist, although the
infoimation so o))tamed is lathei indefinite,
owmtc to the gioat diftirulties emounteied in
comparing stiuctiu.il with chemical ahViations
It is almost impossible to know definitely
whethei theie be at the loot ot all (cllul.ii
digestion (ft/ auto - digestion oi oigans) the
action ot on/ymcs, and it is also difhuilt tu l>c
certain whethoi the ieunent has been fo)mc»d
m the cells ol a paiticulai omau, 01 tiansnutted
to the lattei as1 a /\mogen fiom othei i).uts
The decomposition oi the food pimciples into
sm.illei molecules takes place giaduall}, the
•hnal products oi metaliolism beiiu» foil nod in
the tissue eells wheie these I >odies, 'which aie
circulating m the blood, and aie leqimed foi
the special woik oi the cell, are selected, and
are in p,ut used up to fuimsh t»iieii*\ foi its
specific life pi oc esses, m pait also stoicd up
cithei foi its o\vn use 01 that of other eells
The hnal tiansfoimations lesult alwa}s in the
production of work and heat, and those pioducts
which cannot be used iuithei by the oigamsm
are cxcioted, then fuithei decomposition taking
place outside the annual body One ot the most
marvellous things in the cell lite is the pecuhai
stamp which e.ieh cell 01 gioup oi cell* i»i\os to
its woik, although the ultimate pnnuples, whose
decomposition affords the eneigy necessaiy ioi
the puiticulai role of the tissue, aie the same
What is ordinal ily understood by the teim
digestion, however, is the soi les of changes \\ Inch
tho food uudeigoes in the alimentary c mal,
because it is theie that the most marked altera-
tions take place, and it is w ith pathological dis-
turbances ftom this side that the physician has
to deal in cases of disordered digestion The
food is subjected in the alimentary earral to
processes of two gieat types — mechanical and
chemical They are not, howe\ er, independent
of one another, aftd both are under the influence
of the nervous system In ordci to prepare the
food for absorption, it is necessary to break it
down and transform it into material winch can
-pass into the blood or lymph
SALIVAIU DIGKSHON
Sahvaty thqetfvm has two functions to pei-
foim in the first place, the preliminary prepara-
tion of the food-stuffs for digestion with tho
saliva, gastne, pancreatic secretions, etc , and,
secondly, a specific action, the transformation
of insoluble carbohydrates into devtiniM and a
soluble sugar, maltose
The saliva is formed fiom the seuetions of
the parotid, submaxillary, and sublingual glands
chiefly, with the addition of a mucous fluid from
tho buccal glands It alwa;y H contains suspended
material — foi example, epithelial squames fiom
the palate, salnaiy coipuseles, leucocytes fiom
the tonsils, etc , but when fleshly secreted the
fluid is clear, lapidly becoming cloudy, howevei,
owing to a piecipitation of calcium carbonate
fiom the icmoval of the eaibonic acid which
kept it in solution Noimally it leacts slightU
alkaline, but it may be neutral oi slightly acid
fiom lactic acid fei mentation set up by organisms
acting on food remnants which h»uc adheied to
the teeth Its stiingy like consistence is due to
admi\tme with mucus The speufu giavit}
\aiies from 1 002-1 008 The principal con-
stituents aie watei, salts (especially chloride^
and phosphates of sodium, rtiilphocyanates),
mm in, a diastatic feiment tennerl ptyalin, and
a tiace of albumin Oxygen, caibomc acid, and
a taiily large quantity ot mtiogen aie piesent
The most important constituent is the enzyme,
jttyahn, which is pioduced by the seious so-hvaiy
glands, although it is not piesent in the eells in
the active foini, but lathei as a foi ei miner oi
/ymogeii Tho activity of this enzyme is
destroyed by wanning the sain a to a tempeia-
tuie arxrxo 70° C One may say that it is most
active in a slightly acid medium (due to oigamc
acids) at a tempeiature between 35° and 37° (-
The action takes place rapidly, and is best
studied by mixing saliva with mucilage of
starch, and keeping the mixture at the abo\e-
i Mentioned temperature The fluid first becomes
clcaier, and then tho action runs through the
later stages so rapidly that on examination,
e\en after a few minutes have elapsed, the final
products of the digestion have boon formed
The fiist body that is foi mod is soluble staich
or amidulm, which takes up water, and is split
up into a form of devtrni — ciythrodextrm — and
maltose From the former another dextrin —
achroodoxtnn— and maltose are formed Kiy-
thiode\trm forms a coloured compound with
iodine (of a red tint), while achroodextrm does
not In addition to maltose there is probably
formed a small quantity of another migai,
isomaltose, and perhaps glucose Sulphocyanates
are by no means always present in saliva, only
their presence or absence has no acknowledged
pathological significance
The most important patJiological constituent*
are lactic acid in diabetes (never glucose), uric
DIGESTION AND METABOLISM
367
acid in gout, and uiea in vanous nephritic con-
ditions Certain drugs may be excreted by
may of the saliva, e r/ mercury, iodine, bromine, j
etc Blood or pus may be present in mflam-
matoiy conditions of the mouth I
Nerwnia Mecfiantmi of tiectetion,- -As a rule |
no sain a passes out from a salivary fistula unless I
there bo chemical or mechanical stimulation of j
the sunounding parts , but the mucous secietion !
seems to be constantly produced In man,
horn ever, even the sight 01 smell of food may
set ii]) salivation If the glands be active,
stimulation of the special taste nerves, or the
sensory nerxt's of the mouth, will at once pio-
duce a flow of salrva Mastication greatl) i
increases the flom, ommg to a more fiequent i
stimulation of the neue endings in the buecal I
mucous mconhiane by the substances mhich aie
undeigoing solution oi maceiation Severe '
i in tat ion of the stomach, as in emesis, will pio-
duce sal nation by means of the stimulation of '
the vagus Theie are two gieat sets of noivo
fibres passing to the sal nary glands, cranial and i
SAmpathetie, both containing secretory fibies, |
and in addition the foimei contains \aso-dilatoi,
and the lattci vaso-constnctoi fibies The
same ncives p.iss to the submaxillaiy and sub
lingual glands, while the paiotid has a special ,
supplj It is unnecessary to dcseiibe in this
place the couise of these hbies , suffice it to say '
that the ciamal supply of the two fnst-men-
tioiifd islands is the choida tynipam blanch of '
the facial passing thiough the lingual blanch !
of the fifth nei\e, while that ot the paiotid is |
fiom the glosso phaiyngeal, thiough Jacobson's ,
nerve, the small supeidcial petrosal, the otic
uanglion, and the <iunc ulo-tempoi«il bianch of
the hfth ncne All tin ee glands have a supply j
from the cervical sympathetic On stimulation ,
of the cianial blanches there is an abundant j
\vateiy secietion, pool in solids, while after
stimulating the sympathetic, a spaise secietion, ;
mh in solids and of stringj-like consistence, is
produced Kcflev stimulation fiom the mouth
under ordinal y conditions affects simply the ;
cianial nerves, and inter i upturn in this lenex |
may occur, so that stimulation oi the gustatory
nerves mill not pioduce an eftect During
secretion the tempeiatuie of the saliva nses
slightly alune that of the' blood in the caiotid,
and its pressuie may also use above that of the
carotid Duimg active secretion an electrical
cm rent is produced in the gland, " the current
of action " Niuotin and atropm paialvse secre-
tion, the former affecting probably the nerve
terminations around peripheral ganglia, the
latter the final terminations aiound the secret-
ing acini
The moijt/iolof/ita/ (Jtnnyet in the \alivaty
'/tands during secretion are of importance It
is customary to speak of the parotid as a true
serous gland, the subhngual as a mucous, and
the submaxillary as a mixed gland , but the
human subhngual gland in all piolubihty
produces a mixed secretion, because the
cre¢ic cells lying at the penpheiy of the
mucous acini arc serous in type Serous cells,
as, for example, those of the paiotid, contain at
the beginning of salivary digestion numerous
gtanules in the /one next the lumen of the
acinus, tendering the cell cloudy in appeal ance
\vhile the peripheral part aiound the nucleus is
clearer Gradually these albuminous granules
aie discharged, and the whole cell appears less
opaque The cells which secrete mucin appear
clear and distended befoie discharge of then
contents, mhile after secretion they aie collapsed
Slomly mucinogen gianules form foi a little dis-
tance aiound the nucleus, and then, on taking up
v itcr, these swell and disttnd the free pait of
the cell In all, the type of secretion is the
same, matenal being taken up and stored in
the outei pait of the ceils, and then gradual!}
translormed into mucin or albuminous material
in the mnei pait and passed out as the true
secietion of the acini The part \\hich the
nucleus plays in the piocess is still doubtful
Tht amount nf saliva secietcd dining the daj
varies on an a^elage about \ to 2 lities There
may be a maiked in u ease, as, foi example,
aitei tneicuiy, potassium iodide, pilocarpme,
and many Acgetablc nritauts which stimulate
the bueesil mucous mcmhiane It ma) also be
inci eased in many cases of neivous shock, \vhile
it is often gicatly dec leased in frbi lie conditions,
and may be absent altogether in Instena
1'athologic U changes in the* salnaiy irlands mill
be ii'feired to undei then special headings
* (J \siRir DIOFSIION
(iti^trir Diction — Gastric digest ion is in part
.1 mechanical pioccss, the food substances being
bi ought into a condition of finei subdivision by
moans of the mo\ements ot the stomach, m
pait a chemical one, the finely subdmded food
substances being giadually torn cited into a
moie soluble foim, and one theiefoic bettei
fitted fot absorption Undei noimal conditions
the plot ess of digestion is unaccompanied by
sensation
It is pei haps best to consulei first the chemical
piocess of digestion, piefacing this \\ith a short
ac. count oi the cht natal composition of the f/a*tric
juice
(idstiic juice, as obtained from a case of
gastnc fistula in the human subject by Schmidt,
mas found to be a colomless tiansparent mud of
,i specific grauty of 1 0022-1 0024 On boiling
it becomes faintly opalescent, but yields no
piecipitate Under normal conditions it appears
not to be foinied except as the lesult of stimu-
lation, but G\en in a state *of hunger the
stomach is raiely found quite empty The
quantity present vanes considerably. Any-
thing abo\c 50 co may bo icgarded as patho-
logical Many observeis hold that the small
368
DIGESTION AND METABOLISM
quantity of 1020 cc. normally found duung
hunger has been secreted as the icsult paitly
of stimulation due to the swallowing of saliva,
partly of tho mechanical stimulation aiising
from the intioduction of the gastnc sound
Tho degree of acidity vanos tonsideiably oven
m tho same individual , hut 2 per cent may be
regarded as <i noinul aveiage
In tlie dog, iioin which gastnc juice can be
obtained 111 considciable quantities, and fiee
from the constituents of tho saliva, and in
which its composition has been much moie caie-
fnlly studied than in man, it is <i eolouilesh,
odouiless, transparent, stiongly acid (( on taming
about ."5 per cent hydiochlonc ac id), and dctn fly
peptu fluid of an .lAeiage specific giavity ol
10017 It may he Kept an indefinite time
\\ithout showing signs of putief.utne decom-
position It is slightly dc\tio-rotatojy, and
the iisu.il ptoteid ic.utions On bcinu
cooled to 0° (1 a hue pi capitate ot gieat peptic
activity f onus The chief oi^anic constituents
are the enzymes, pepsin, lennm, and possibly
invcrtm, along with ti.ioes ot mm in and pioteid
convertible into albumose and peptone on stand-
ing The moiganic constituents aie (hloiides
ot sodium, potassium, calcium, as well as ti icon
of magnesium and nun 1'hosphatcs are also
present in very small quantity
The fiee acid of pine gastiic juice is hydio-
ihloric, the most important piooi of this bemg
that the quantity oi chloime pieseut is gieatei
than the ihcmical equivalent of the total moi-
ganic bases.
CoiulttiMt1* iu/!nen(utf/ the tii'dtttftn *9t»f/ms
find Mode of Jf1ot ttuitton of the Constituents of
t/ie (*aktnc ,/inre — The secietion is uoiiiially
mtci mittent It may be induced ( 1 ) by ps} chical
stimuli, ?</ the sight, 01 e\en the thought of
iood, (2) iefle\ly by stimulation of the neives
of taste, oven wheie no food is allotted to elite?
the stomach, as in the pseudo-feeding of dogs
aitei the establishment ot a Paw low fistula , and,
lastly, by the enti aiiot ot foodoi othei substaiues
into the stomac h
Simple mechaiiKal stimulation ot the gastiic
mticosa pioduces only A slight local secretion
It is unlikely, theiefoie, that the noimal secie-
tion is at all l.ugcly dependent on mech.ime.il
irritation Digestible solid substances mixed
with saliva on then entiance into the stomach
induce an immediate slight local secietion due
to mechanical nutation Aftci about fifteen
minutes theie follows a second Deletion of
gastric juice m much largei quantity fiom
the whole surface of the gastric mucosa The
latter secretion is believed to follow as a lesult
of the absorption of the small quantities of
albumose and peptone produced by the action
of the gastric juice secreted m consequence ot
the mechanical Humiliation.
In the earlier stages of digestion tho acid of
the gastiic juice is neutiahsed by the alkali of
the food and of the saliva For a variable
period (three-quarters of an hour according to
van d Velden) free hydrochlouc acid cannot
be detected, the hydrochlouc acid entering into
loose combination with the albunioses, peptones,
and .albumins (to form acid albumin m tho latter
case) as quickly as it is secieted Dining this
pcnod — the amylolytic stage of gastric digestion
— the ptvalm ot the sain a continues to cxeit
its action upon the caibohydiato matenal of
the food As digestion piocecds the acidity of
the JUKO gi actually inoi eases
The hydiochlouc acid and pepsin ot tho
gastric juice aie pioduced by different cells 111
the gastiu glands In the caidiac legion oi the
stomach two varieties ol cells aie tound, the
centiall) placed, chief oi adelomoi phous cells,
and the parietal, delomoi phous 01 ovyntic cells
In the p>loi ic legion one kind of cell alone is
piosent, tiud that lescmbles tho ceiiti.il cells ot
the caidiac legion \eiy much moie closely than
the panetal ones The pyloiie secietion, when
obtained fiee tiom the tardiac one, is loimd to
be alkaline, and when acidified w **\ hydro-
chlouc acid it possesses pcptoiiiniui; po "
r!Mie amount of pepsin which it contains is,
ho\ve\ei, much smallei than that of the caidiac
iei>ion The secretion oi the caidia*1 region, on
the othei hand, contains both pepsin au hydro-
chlonc acid 'Phcsc, along with other idcts,
indicate the parietal cells to be the pioduccis of
the hydiochloiic acid, and the cential tells to be
the oiit-matois ot the pepsin The hito of the
toimation ot the lennin feimcnt 01 its pie-
cuihoi is uncertain With leg.ud to the
lnstologu.il appeal ancch of tlie gland cells only
a lew woids arc iiecessaij The cential cullh m
the resting condition aie filled with distinct
gianules, which, duimg digestion, deciease in
number Typically, the granules are situated
chiefly in the innei orluunnal paits of the cells,
the outei /one oi the cells showing a complete
absence of gianules In other laiei cases the
gianules aie found scatteied thioughout tho
whole body of the cell, and the deciease is a
gcneial one
In the ovoid parietal colls the gianules aie
much smaller, and the changes not so distinct
The granules in the cential cells consist not
only of fully formed pepsin, but of a precuisoi or
ssymogeu, which, under the influence of dilute
acids, and also during active secietion by the
cell, is converted into pepsin To give a full
pi oof of this statement would take up too much
space The salient points of difference t ^een
the zymogen (pepsmogen) and the <* me,
pepsin, are that the foimer is insoluble in
glycerine, not easily destioyed by alkaline solu-
tions, and possesses no digestive activity until
converted into pepsin by dilute acids The
latter, on the other hand, is soluble m glycerine,
very easily destroyed by dilute alkalies, and is
an active digestive enzyme
DIGESTION AND METABOLISM
369
The distinction of rennm from its zymogen is
founded on similar facts
The yeivvH* Meeluuiiani of Secretion -The
ttecretoiy wives aie the vagi In a dog, in
which a gastnc fistula had been established and
the oesophagus cu' thiough, the eating of food
induced an nninodi.ite secretion of gastuc juice,
accompanied byicddeinng of the gastiicmueosa
owing to vascular dilatation This icflex secre-
tion ceaHed to occur after both vagi h.id been
divided Stimulation of the peripheral ends
oi the vagi/' .lowly repeated induction shocks
«dso piod uc eel secretion I
In a human subject in whom the lumen of
th'i a'sophagus liad become closed so that a
gastric fistula h.id to be foi med, the chewing of
food, none oi which enteied the stomach, jno- ]
duced u copious fio\v of gastuc juice |
The Motoi Mtchanwti of (Jattrtc JJiye^tion —
The Htoniiich is usually closed at both its
ounces, the caidiac and pylone openings, by the
contraction of the sphnu'tei - like, cnculaily
in ranged muscle fibres The caidiac ounce is
r on (1 in nig each act of sv\ allowing at the close
of the penstaltic con ti actions of the a-sophagiis,
and the pyloius is open fiom time to time to
allow the passage of the liquefied iood mateiial
01 chyme into the intestine Dm mjr the process
•of digestion the stomach walls aie in continual
pel istaltic movement, thus ensuung the thoiough
•uluuAltueof the food with the gastiicsceictiou,
.ind also permitting the mechanical subdivision
of the food masses JJy these con ti actions the
food material is propelled in two dn ections, the
eiicumfeiential poitions of the food passing
towards the pyloius, while the ccntial poitions
pass to wauls the caidiac ounce This cnculatoiy
inovement brings the digestive seciotion into
intimate contact vuth the food substances
The muscul.li movements aie most active in the
a ej» ion boidermg upon the py loi us (anti um pyloi i),
which foi this leasou is sometimes sepaiated by
an oblique fuuow fiom the icmamdci ot the
stomach In the eaily stages of digestion the
pyloius is firmly closed, but towaids its tei-
unnation the closuie becomes much less him, so
that the conti actions of the autrum pylon
succeed in propelling the more fluid portions of
the mass thiough the pylouc opening Cold
water is said by some to produce rapid opening
of the pylorus
The gastric movements arc bi ought undei
the control ot the nervous system by means of
two sets oi fibies The \agi contain accelerator
fibres, so that their stimulation induces penstaltic
movement Inhibitory imposes are transmitted
through fibres, which in the nog leave the cord
by the anterior roots of the fifth to the eighth
thoracic spinal nerves These fibres thence
pass into the sympathetic system, have their
cell stations m the ccehac gang] ion, and ultimately
reach the stomach by way of the splanchnic
T/te dttiatton of digest ton, m health vaucs con-
siderably according to the nature and quantity
of the food taken, and also to individual idio-
syncrasies The normal limits lie between three
and seven hours aftei a substantial meal, c </
Hi eg el's test meal A longei stay of food
mateiial in the stomach indicates motor m-
sufticu'ncy
FUNCTIONS 01- lilt, (lAS'lRIC JUIC'K
Digestion eommeix c& in the stomach In the
mouth the food substances become mixed with
the sail \ a, but then stay there is too short to
allo\v of much digestive action taking place.
Tho chief changes pioduced by the gastric juice
aie the following —
1 The soluble nutiimcnt, v\hich has escaped
solution by the saliva, is dissolved
2 The ptyahn of the saliva converts the
staioh into dextnns and maltose 1 his action
continues as long as theie is no free acid present
m the stomach
3 The acid of the gastric juice bungs into
solution any earthy phosphates or carbonates
introduced with the food
4 The gastuc juice, in vntuc of its pepsin
and hydrochlouc acid, dissolves insoluble and
coagulated proteids and then allies, converting
them into bodies icsemblmg globulins These
proteids, which aie aheady in solution, become
chemically altered The pioteids undeigo con-
veision into a body (acid albumin) pi ecipi table
on initialisation, and not coagulable by heat
At A latei stage bodies aie formed which are not
piecipitable by neutralising the fluid, and as
digestion pioceeds the solubility of the bodies
formed met eases, and then piecipitabihty by
various chemical agents, e </ satuiation with
neutral salts oi the alkalies and magnesium,
solutions of salts ot the heavy metals, alcohol
and stiong mineral acids, diminishes They
also become more easily diffusible through
animal meinbtancs
A chemical classification of the diftcient pio-
ducts of gastric digestion has been founded upon
these differences of solubility and precipitabihty
This classification is oi consideiable theoretical
mteiest , but on account of the complexity and
time-consuming natuie of the methods employed
foi the complete sopaiation of the different pro-
ducts, it has not, as yet, become' of much
impoitance in practical medicine A very brief
account of the most important facts must theie-
foie suffice The final product of gastuc
digestion is called peptone The bodies repre-
senting the intermediate stages between it
and acid albumin are called albumoses (or
pioteoses) The albumoscs are all precipitable
by saturation with ammonium sulphate, whereas
peptone is not precipitable by this salt Certain
of the albumoses are also piecipitable by satura-
tion with sodium chloride or magnesium sulphate
in ncutial solution, and these have been named
24
370
DIGESTION AND METABOLISM
the primary albumoses The rcmaimug albu-
moso la not precipitable by saturation with
sodium chloride in neutral solution, and it is
named deutero-albumose
The pepsin and hydiochlonc acid probably
cxct as hydrolytic agents This conclusion is
supported (1) by the fact that the digestion oi
caibohydrates by the enzyme ptxalin is known
to be hydrolj tic , (2) by the fact that sunilai
products to those of gastric digestion may be
pioduoed by boiling piotoids with dilute mineral
acids, winch are known to act as hydiolytic
agents , and (3) by the fact that peptone maj
be conveited by certain dchydiating agents into
bodies lesemblmg natne pioteids
With regard to the iclativo digestibility oi
different piotoid and albuminoid bodies, the
article on diet should be consulted
Comfttioni aftetttny th? mjmlity of action of
pepsin ami hydiotMoi ic m t</ — The most favoui-
nblc degree ot at idity is about 0 2 pei cent
hydrochlouc acid Othei aeuls may replace the
hydrochloric, but all of them aie much less
efficient
The most favourable tempera tin o fin thi
aetion of pepsin lies between 3.T (' and .10° T
Tn neutial solution pepsin is destioyed b\
heating to 55° C , but the addition of peptones
to the solution laises its lesistmg powei, &o that
a tcmpeiatuie of 60° (/ becomes necessary for
its destruction In the dry condition it may be
heated to a tempciature of over 100J <' without
losing its activity Up to a ceitain maximum
an increase in the quantity of pepsin accelciates
digestion
Numerous oigamc compounds, \\hich in
dilute solution destioy, 01 at least inhibit, the
activity of micro-oigamsms, exert lit tic deleterious
action on pepsin Arsemous and salicylic acids,
phenol, thymol, and chloroform in dilute solution
only slightly retard peptic digestion Neutral
salts of the metals of the alkalies and alkaline
earths lowei the activity of pepsin Alkalies and
salts of the heavy metals rapidly destioy pepsin
It is of some importance to remember these facts
in connection \vith the administration ot drugs
Accumulation of the products of digestion
lessens greatly the rapidity of the action oi
pepsin. The duration of peptic digestion is
thus gicatly lessened by the simultaneous
absorption of peptones by the stomach
Tn virtue of the presence of the remunfei inent
the gastric juice pioduces coagulation of the
cascmogen of milk by converting it into casein
This action takes place in neutral solution pnoi
to the appeaiance of free hydrochloric .icid in
the gastric contents The cascmogen of milk is
also precipitable as such by the acid of the
gastric juice/cand the precipitate is afterwards
peptomscd The gastric juice splits up cane-
sugai into dextrose and lievulose This action
is said by some obseivers to be due to a ferment
tnvertin.
Glucose and lactose are also said to be split
up into lactic acid by means of an enzyme,
even nhcii Iwictenal action is excluded This
enzyme, however, has not been isolated, and its
existence is doubtful The quantities of lactic
add so formed aie, in any case, so small that
the occurrence oh appreciable quantities is
certainly to be regarded as pathological
The hydrochloric acid of the gastric juice,
in addition to its digestne action, acts as a
yernundal tif/tnt When the secretion of hydro-
chloiic and is deficient, the gio\vtb of micro-
ni «;anisms occuts mueh moreieadilv Amongst
these organisms may be mentioned the bat teiium
lactis, \vhich by its action on caibohydiates pio-
duces Liftu acid lUetcnal decomposition of
pioteids is also liable to oecui
I K i ami tuition oj i/a^ton content* — Methods
used to obtain these — The next point to consider
is the examination ot the qavtitc contents It
has alieady been mentioned that mechanical
and electrical stimulation may be used to
produce secretion of gastric juice The most
natural stimulus, ho\\o\ei, is the introduction
of digestible food material The object of the
examination of the gastnc contents is to find
out how the stomach Julhls its normal task oi
pepUmismg food material and piopelling it into*
the intestines as the add chyme Vor this
purpose a considei able \anety of "test meals""
has been employed
The tollowmg aio the moio important ones —
1 A test breakfast (Ewald and lioas), con-
sisting of 70 gms \\hitc biead and 300-400 cc.
of weak tea or watei
2 A lunch (G See), consisting ot 100-150
ijjms bread, 00-80 gms of finely minred meat,,
and a large glass oi \\ater
3 Ricgel's test meal (given from 1-2 PM),
consisting of a plate of soup (about 300 u ), A
beefsteak of 150-200 gms, potatoes 50 gms,
and white bread 50 gms
Klempcrer, Bourget, Jaworski, and Glu/mski
have also proposed test meals
hi considering the advantages and disad-
vantages oi these meals, it will bo found most
convenient to take Kwald's breakfast and
Illegal's dinner as types ot the two extremes-
in quantity
The chief advantages claimed foi Ewald'n
method are the following —
1 The composition of the meal is definite
and simple
2 The siphoning off of the gastric contents
(an be undertaken after a short and definite
inter \al (1 hour)
3 Practically every patient is able to take
the meal on account of its small size
Kiegel's meal, on the other hand, is somewhat
indefinite and complex in composition It is
difficult to h\ upon the most favourable interval
of time after the meal, for the obtaining of the
gastnc contents, as it \anes in individual cases,.
DIGESTION AND METABOLISM
371
according to the degree of motor arid peptic
efficiency, from 2-6 hours Usually the examina-
tion of the contents is undertaken 3J houib
after the meal Lastl}, tho meal, on account
of its large quantity, is not easily taken by all
patients HiegclVi meal has, however, some
M\ vantages not sh.ucd by that ot Ewald and
Boas In tho fiist place, it lays a much gicatei
demand upon the many-sided functional activity
of the stomach, and theiofore frequently gives
one a bettor insight into what tho stomach
M really capable of perfoimiiig The icsults
obtained by thcHu methods do not always
agiee The total acidity is usually found highoi
aftoi Kiegel's test me,il than after that of Ewald
,ind Boas On the other hand, one must not
omit to mention that in some cases, in which
tho pi od net ion of hvdnx hlonc acid is gieatl)
dimnnslicd, e (/ in cai<inoma vcntiidili, fice
hychoc hloiu acid may be found after E\\ aid's
test HUM], wheieasaitci that of Uiegel » negative
result of the examination is not infrequent
The explanation of this appaient contradiction
lies in the fact that the large amount of pioteid
in Riegel's test meal is able to cntei into l<x>se
(ombmation with all the hyhochloiic add
secreted Another important advantage is that
it may be employed in the same way as the
similai meal advised by Leubo for testing the
motoi cfhciency of the stomach Foi genei.il
uso, if only one method be employed, piobabh
Kvvald's is the moie convenient
The gastric contents may be obtained by
means of a soft i libber tube or sound about
75 cm in length, and oi variable diameter,
6-7 mm being the aveiage, to whose upper end
.1 small glass tube (about 4 uu hes in length) is
connected by means of lubber tubing The
lower end of the sound may be closed 01 possess
a tciminal apeitiuc, but in all cases should
have one laige 01 several small (E\vald and
llosenheim) Litcial openings The piescnc e of
the latuial openings lessens the nsk of obstruc-
tion by food particles The sound, having been
rcndcicd aseptic, in placed in waim \\atei In
syphilitic, tuberculous, 01 cancel ous cases,
separate sounds ought to he used foi each class
of c«ise The upper glass end is then put into
a vessel, which may be held by the patient
The lower end of the sound is next introduced
into tho patient's mouth, and pushed as far
back as the root of the tongue (for this manipu-
lation tho introduction of tho operators fingei
is unnecessary) If the patient now swallow
once or twice tho tube will glide into the uppei
end of the oesophagus, its descent into the
stomach being afterwards aided by slowly and
rhythmically pushing it onwards until about
45 cm of tho tube has been mtioduccd
For obtaining tho gastric contents one of two
methods — expression or aspiration — may be
employed The foimer method is the simpler
and the one most frequently used The patient
is requested to tike a deep inspiration, and then
by the contraction of his abdominal muscles to
expel the gastric contents up winds through the
sound into the vessel prepared for their recep-
tion The index finger should then be placed
on the opening of tho glass tube and the sound
lapidly withdrawn The closure of the lumen
of tho tube by the finger prevents the escape of
the fluid contained within the sound and rubbci
tube By removing tho finger the contents are
then allowed to fluw into the leceiving vessel
For the aspuation moth ml, Boas' aspnatoi, or
other similai instrument, may be employed A
dcsmption of the different forms in use is un-
nruessary, snue the expression method has the
.id vantage of greatei simphc ity, and is quite as
efficient
1 1 (Hmutil < ia jni nation of the </ai>ti »c content*
— A Macioscopic examination — The chief
points to note in the macroscopic examination
arc the quantity, consistence, odcmi, and coloui
of the contents, as well as the presence of any
foreign constituents, such as bile, blood, ab-
noimal quantities of mucus, etc
Befoie forming an opinion with legard to the
'/nantity, one must feel sure that the tota
contents have at least been approximately ob-
tained The quantity is, of couise, largely
dependent on the form of meal taken No
conclusion can he chawn from the quantity of
the contents as to the peptic activity of the
gastnc juice The digestive actnity of the
juice can be better ascertained from the other
maeioscopic appearances of the contents From
the quantity found, however, one can infer
whethei motor insufficiency of the stomach is
present oi not In cases of mci eased motility
the stomach may be found neatly empty after
Kiegcl's test meal within a shorter mtenal than
the noimal one of seven hoius In other cases
the quantity is abnormally laige, or the stomach
is found to still contain food residues after the
lapse of seven houis These are pn manly cases
ot motoi insufliciency As will be seen later,
motor and sccietory insufficiency lun by no
means always parallel
Lastly, in some cases a larger quantity is
found than that which was mtioduccd into the
stomach These cases were hard to explain
occoidmg to the foimer MCW that watei was
absorbed fiom the stomach Moic recently,
however, von Menng has shown that not only
is little oi no watei absoibed by the stomach ,
but, on the contrary, the absorption of ceitam
substances, e </ sugar, dextrin, peptones, and
alcohol, is associated with a secretion of water
into the stomach
It is f uither important to note the presence
or absence of undigested food residues, and also
whether these food lesidues aie chiefly carbo-
hydrate or chiefly proteid in nature A fine
uniform liquefied mass suggests active peptoms-
ing power, accompanied, it may be, by hypci-
372
DIGESTION AND METABOLISM
acidity. Undigested particle** of food suggest
the presence of subacidity. Abundant starchy
residues associated with good proteid digestion
justify the conclusion that hyperacidity is
present. A certain opinion can of course only
be formed with regard to the secretion after a
detailed chemical examination. The necessity,
however, of a careful preliminary macroscopic
examination may be illustrated by the following
examples — In one caso there may be found
only a small quantity of hydrochloric acid, and
yet the macioscopic examination may indicate a
fairly complete pcptomsation of the food In
another apparently bimilar caso of subacidity,
undigested food particles may be found in
considerable quantity If in these two cases an
estimation of hydrochloric acid had alone been
made, little or no difference in the conditions
would have been detected The consideration
of the results obtained by macroscopic examina-
tion, combined with th.it of the icsnlts of the
chemical examination, shows the impoitant
difference that in the formei case the quantity
of popsin is much larger than in the lattci
The odout of the gabtnc contents it> aluo of
considerable significance Normal]/ they have
no distinctive odour In ueitaui pathological
conditions they have a somewhat rancid smell
owing to tho presence of free fatty acids In
cases of subacidity they sometimes have a
putrefactive odour o\\mg to the decomposition
of pioteids brought about by the gtoitth of
micro -oigamsms In cases of intestinal ob-
struction or of an abnormal communication
between the Htomach and the intestines they
may h.ive a f.ecal odoui
Mucus in considerable quantities, blood, l>ile,
and pus arc abuoinml constituents that may
occasionally be found
Mucus, if present in large amount, can easily
be recognised by its physical characters, and by
the fact that it yields a precipitate on the addi-
tion of a little acetic acid It is usually found
in the upper part of the gastric contents when
they have been collected in a vessel The
quantity of mucus normally piesent is small
The Colow — Blood, when present, may pro-
duce cither a i eddish or brown tint in the
gastric contents In the former case it has
been freshly shed, and microscopical examination
frequently icveals intact red blood-corpuscles
In the latter the hemoglobin has become de-
composed into inethoemoglobm and acid htematm
(see " Htcinatemesis ").
Bile and intestinal juice are not infrequently
met with even under normal conditions, the bile
giving a greenish tint to tho gastnc contents
The usual tests for its chief constituents may
be employed*1 in its recognition The presence
of intestinal juice is proved by testing for the
pancreatic enzymes
Pus is very rarely found It may be re-
cognised on microscopical examination, and by
means of the chemical tests used for its recog-
nition in the urine
tho macroscopic appearances are very character-
istic The gastric contents, when collected in a
vessel, show at least three distinct lay ex s The
uppermost layer consists of foam formed by gas
bubbles which rise to the surface, tho middle
layer is a more or less turbid mud, and the
lowest one consists of a sediment composed of
fine carbohydrate residues This condition is
found under circumstances which allow stag-
nation of the gastric contents, as for example
in motor insufficiency. The quantity of free
hydrochloric acid is usually increased rather
than diminished In this icspoct gaseous fer-
mentation is in striking contrast with other
forms of f ei mentation, e.<f lactic acid fe,i menta-
tion, which aie practically never found except
IP rases ot subacidity The mix tin o of gases
piesent is occasionally inflammable Chemical
examination has shown the piesence of \anablc
quantities of the follow ing gases — Caibon
dioxide, hydrogen, niaish gas, and acetylene, in
addition to mtiogen and small quan titles of
oxjiren The last t\\o gases aic demcd from
atmospheur an uhich haa been s\v allowed
Sulphuretted hydrogen is also occasionally
found in the gastnc contents, but it is not
usually found in typical cases of gaseous
fermentation
Foi the examination of \omited mateiial tho
same methods, macroscopic and chemical, aie
used as for the examination of the gastric con-
tents obtained by the use of the sound The
\onuted mateiial may consist of mucus alone,
mucus mixed \vith bile, or moio 01 less digested
food mateiial Avith admi \ture of any of the
pathological constituents alieady mentioned
In certain eases the examination of the gastric
contents after a test meal lequires to be supple-
mented by a KimiLit examination in a state of
hunger, i e in the nioining before bioakfast.
The picsence of any quantity above DO cc is to
be icgauled as pathological Quantities above
50 cc are usually found in cases of motor m-
Hiifficiency or obstruction, and sccondl) m cases
of hypersecietion
JJ The chief mo> jthofoyiral constituents that
may be noted on nut / owopical examination arc
the following — Undigested food residues, eg.
muscle fibres, staich gianules, plant eclls, fat
globules, etc , cell nuclei, Hquatnous epithelium,
columnar epithelium, mucous* colls, blood and
pus coipuscles, Hiunll poitions of the gastric
mucosa, particles of tumours, and various micro-
organisms, ty yeast cells, sarcma vcntuculi, and
immeious foims of bacteria
6*. Chemical examination of the ffaitiie ion-
tents.- Prior to tho chemical examination the
gastric contents should be filtered The filtrate
alone is used for the examination
] The reaction of the nitrate should be
DIGESTION AND METABOLISM
373
ascertained by the use of blue and red litmus
papers.
2 If the reaction be acid, the pxosenco or
absence of free hydrochloric acid P*" "
ascertained There are a number of organic
colouring matters, which change in colour in
the presence of fiee hydrochloric acid even when
the acid is m very dilute solution , while they
show no change of colour in picseuce of such
strengths of organic acid solutions as arc ever
found in the gastric juice The most commonly
employed colouring matters are tropiEolm 00
(saturated alcoholic solution), which is changed
from yellow to red by irte hydiochlonc acid,
methyl violet ( 1 per cent aqueous solution),
which becomes blue, and congo red, which is
converted into a daik blue The most im-
poiUnt objection to the use of all these is that
alburnosoH and peptone when present pi event ot
lessen the coloui change by entering into loose
combination with more or loss oi the hydro-
chloric acid This objection doe* not hold good
for Gun/lmig's tc-«t (iim/buig's reagent has
the following composition - Phloroglucin 2
gins , vanillin 1 gin , absolute alcohol JO cc \
few drops of this yellowish fluid die mixed in <i
porcelain basin with a very small quantity of
the filtiate, and the mixture evaporated to diy-
nes,s over the open name If free hydrochlonc
acid be present, .1 carmine led lesiduo is loft ,
but if free- organic at ids only be piosent, a slight
yellowish icsidue is left.
The simplest test foi lactu acid is Uftel-
mann'u reagent (2 per cent aqueous phenol
solution to which are added a few drops of
tinctuie ot the peichlorulo of 11011 until the
fluid becomes of a deep ameth>st-hlue coloui)
This reagent should ah\ ays be fleshly pi epared
before use It is not advisable to test toi
lactic acid by its means m the nitrate itself, as
othei substances, which share with lactic acid
the powei of convex ting the blue into a tanan
yellow solution, may bo piescnt in the filtrate
Amongst those may be mentioned glucose, phos-
phates, alcohol, oxalic, citric, and tattanc adds
About 10 cc of the tiltrate tire concentrated to
a thin syrup by e\aporation on the water bath,
thoroughly extracted \uth ether, using about
50 cc. in all The ethereal lajer is then separ-
ated, and evapoiatcd to dryuoss on the \\.itei
bath The residue is dissolved m water, and
tested by means of Uffolmann's reagent For a
quantitative estimation of lactic acid the extrac-
tion with ether must be more thorough At
least six extractions, using 100 cc of ether each
time, should be employed The residue after
evapoiation of the cthoi should be dissolved in
a known quantity of water and titrated with
decmormal caustic soda solution Each cc of
the decmormal alkali is equivalent to 0090
gms. of lactic acid
Butyric and acetic acids are also sometimes
found m very small quantity
The nitrate of the gastric contents may also
be tested for the different foims of albuinoses
and for peptone, but as yet the examination has
"* obtained much practical importance
The presence of pepsin may be recognised bj
means of an artificial digestion Ten cf of the
filtrate are placed in a test-tube, hydrochloric
a',id being added, if necessary, until congo red
paper is lust turned blue, and a cirmlai disc of
hard-boiled white of egg 1 5 mm thick and 10
inn in diameter is placed m the fluid The
disc may be cut from a hard-boiled egg by
mouns ot a Valentino's double-bladed knife and
a coik-boier The test-tube is then placed on a
\vat« r b.itli ^t 40 V.1 If the quantity of pepsin
be normal, the albumin disc should be com-
pletely dissolved in a half or at most a v hole
horn
To fc<*t iot the picscncc of lennm, 10 cc of
the LMstnc nitrate arc accurately neutralised by
the addition of decmormal caustic soda solution
A few drops ot the neutial fluid are then added
to 10 cc of milk in a test-tulx), and the mixture
is placed m a w.itor bath at 40° C If renmn
be present m sufficient quantity, coagulation of
the milk should bo complete in ten minutes, or
at most half an hour
Quantitative estimation1* of the chief constituents
nj the f/astrirjiltiate —
The total acidity may be estimated by the
following method — To 10 cc of the gastric
tiltrate, diluted with a little water, a few drops
of alcoholic solution of phenolphthalein are
added Decmormal caustic soda solution m
then gradually added to the mixture placed in
a beaker until a permanent pink colour just
ioitns It is customary to express the degree ot
acidity so found by a tigurc stating the number
of cc of decmormal caustic sod.i necessary to
neutralise the total acid m 100 cc of the
filtered gastnc contents If, foi example, 5*7
cc of decmormal canstu soda were required to
neutralise the acid in 10 cc of the gastric
filtrate, then 57 cc would bo required to
neutialise the acid m 100 cc , and the acidity
would be 57 per cent
Other mdicatois, eg litmus, may be used in
the place of phenolphthalein The indicator
chosen should be employed for all the estima-
tions of one series This is a necessary pre-
caution, as the lesults for the acidity obtained
by the use of different indicators do not always
coincide when proteids are present in the acid
fluid. If, for example, a drop of phenolphthalein
solution bo added to a proteid one, which leacts
neutral towards litmus, the addition of a small
quantity of decmormal caustic soda will be
found necessary before a permanent pink colour
of the solution is secured Tlife total acidity
\ aiies within wide limits even under physiological
conditions 50-75 per cent may be given as the
average.
The total acidity of the gastric filtrate is
374
DIGESTION AND METABOLISM
made up of the following factors — (1) free
hydrochloric acid, (2) combined hydrochloric
acid, (3) acid salts, and (4) organic acids Tho
quantity of organic acids present is usually HO
small that it may bo neglected A method for
the estimation of the most important one of
these, namely, lactic acid, has already been
given. For methods of estimating the other
organic acids see " Liteiatuie "
Probably the simplest and yet accmatc
method of estimating the fiee hydrochloi ic
acid is Flemcr's modification of that of Mint/
To 10 cc of the gastric filtrate placed in a
bcakci are added about twenty-five diops of
Gunzburg's reagent A drop of the mix tine is
cautiously evaporated to dryness over the open
flame A curinmo-red residue indicates the
presence of fiee hydrochloi u; acid Foi the
quantitative estimation of the free mineral acid
dccinormal caustic soda is .gradually added horn
a burette until a drop or two of the mixture
yields no red residue on heating Aftei making
a preliminary estimation a second one should
always be pcrfoimod, using the result of the
hrst as a guide The number of cc of dcci-
normal caustic soda used indicates the quantity
of free hydrochloric and expi eased as so many
cc of a docmormal hydioehlonc acid solution
The percentage of hydioehlonc. acid is obtained
by multiplying this icsult by 00365 Although
this is always given as a method for the estima-
tion of the ./we HC1 alone, it is doubtful whether,
after all, some at least of the combined HOI is
not also estimated
The acidity due to actd mitt may be estimated
by Leo's method. 10 cc of the gastric nitrate
arc mixed with 5 cc of a saturated solution of
calcium chloride, and the fluid titrated with
docmormal caustic soda m piccisely the same
manner as already described under estimation
of the total acidity
To 15 C( of the gastnc filtrate IK then added
1 gm of finely powdered pure calcium carbonate
The mixture is thoroughly shaken, and then
filtered thiough a previously diy filter into a well-
dried beakci Calcium chlonde, acid phosphate,
thecxcessof calcium carbonate, and carbondioxide
aie present in the filtrate The carbon dioxide
is removed by passing a stream of air thiough
the fluid by means of a hand bellows connected
with a hue glass tube dipping into the fluid, or
by moans of an aspirator 10 cc of the filtrate,
now freed from carbon dioxide, aie accurately
measured out, mixed with 5 cc of a satin ated
solution of calcium chloride, and titiatcd \\ith
decmormal caustic soda as before The latter
result gives the acidity alone due to acid salts
The former result gives the total acidity
A few wor&s are nocessaiy to explain the
principles upon which Loo's method is based
Solutions of free acids on being shaken with
calcium carbonate in the cold are completely
neutralised, while fluids containing acid (/ e
dihydrogcu) phosphates after similar treatment
letain their acid reaction In a mixture of free
acids and acid phosphates, one can therefore
exclude the acidity due to free acids by the
addition of calcium carbonate, and then estimate
m the filtiato the acidity due to acid phosphates.
Tho soluble calcium salts which are foimed by
the interaction of calcium carbonate with the
fiee acids present (chiefly hydrochloric) react
with sodium dihydiogeu phosphate to foim
sodium chloride and calcium dihydrogen phos-
phate One then estimates the acidity of the
latter salt, which icquires twice as much caustic
soda to conveit it into the neutial calcium
phosphate as is necessaiy foi the initialisation
of the corres]X)ndmg acid phosphates of sodium
and potassium The following equations will
help to lendei the mattei cleai - ^NaH2l'04 +
2NaOIi = 2Na ,HV( >t + II ,() , whereas 2NaH ,?O4
+ 4NaOH f 3("dCJl2 -(1a,("J>O4)>! + CJSTaCl + 4H2O
To ON ei come this difficulty, one of two ex-
pedients may be cmploved The total acidity
may be estimated m the usual way without the
addition ot cilcmm chlondc The second titia-
tion may be cained out exactly as befoie The
numbet of cc ot caustic soda used in the second
titiation would, howevei, jcqune to be divided
by two This division by two becomes un-
neicshaty it both estimations aie peiioimcd
under the same conditions, namely, the addition
of excess of calcium chlondc Since the second
method is the simpler, it IH almost imanably
employed
The total quantity of hydioehlonc acid — fiee
and combined — IH easily ascertained from the
lesults alicady given Jt is equivalent to the
total acidity minus that due to acid phosphates
and lactic acid it picsent
Foi the estimation of the total "physiologi-
cally active" hydrochloi ic acid (free and com-
bined) uumcious other methods have been
employed , of these Martins and Lattice's ap-
pears to bo the most ace mate As the method,
however, is somewhat too complex for clinical
use, a brief sketch of the pimciples upon which
it is founded must here suffice The total
chlorides m 10 cc ot the gastric nitrate are
first estimated as in the urine by Volhard's
method The quantity of chlorine m the ash of
another 10 cc is then estimated and leckoned
in terms of hydioehlonc acid By subtracting
the latter result from the formei, one obtains
the chlorine present as free and combined hydro-
chloi ic acid
The loosely combined hydrochloric acid is
equivalent to the total acidity minus that duo
to acid phosphates, free hydrochloric acid, and
lactic acid if present Tho combined hydio-
ehlonc acid is in loose union with amido-acids,
albumoses, and peptones The total hydrochloric
acid is sometimes termed the "physiologically
active " acid, because the loosely combined is as
important in peptic digestion as the free
DIGESTION AND METABOLISM
375
TUB MOTOR ACTIVITY OF TUB SroMAc'H may be
tested by seveial methods. 1 Piobably the
best ot these for practical purposes is that of
Leube Seven hours after the taking of a test
meal similai to that ot Itiegcl, an examination
is made with the gastuc bound ITndci noini.il
conditions the stom.ich should then be found
empty, but in cases of motor insufficiency the
amount of fluid vanes a(coiding to the seventy
of the case
2 The Mi/of met/Ml of Ewald and titevei s foi
testing the motoi efficiency of the stom ich is
founded upon the fact th.it salol -a ( ompound
of Haluylic acid \vith ]iheuol — is not decomposed
in and solution, but leadily undergoes deconi-
position in alkaline solution into phenol and a
sahcylato of the alk.ih employed This dc< om-
]X)sitioii cannot take place in the stomach, but i
occuis whenever the salol passes into the small
intestine The sahcylate thus foimed is ab-
soibed, and cxneted in the urine as sahcyluiu
ooid, which gives a violet lolom \vith feni(
ihlondc If 1 gm of salol be given to a healthy
individual dining digestion, th<» icaction with
feirie chloiide should .ippear in the urine aftei
hall or at most tl nee -quarter of an lioui
Delay in the appeal am e of the le.ution indi-
cates a letention of the « ontents of the stomach
The salol test has, ho\\evei, tinned out to be
far horn lehable Stein has shewn that salol is
absorbed horn the stomach itself, and th.it the
pioduets of its decomposition may alters aids be
detected in the mine
J A thud method — th.it pioposed by Klem-
poioi — eonsists in intioduemg into the stomach,
previously fieed fiom food lesidues, 100 cc of
olive oil Aftei t\\o houis the gaHtnc contents
are obtained bv me ins of the sound, the com-
plete lemoval of the oil being after\\aids ensuied
by lepeatcdly washing out the stomach with
wdtei The oil, aftei l>omg sepaiated fiom the
water in a sepaiatmg tunnel, is measuied The1
<liminution in quantity expresses the1 amount of
oil which has been expelled into the intestines
Klemperei found that under normal conditions
70-80 cc of oil \veie expelled into the intestines
This method, although of c onsidciahle scientific
value, is obviously one ill suited foi piactic.il u>e
4 L.istly, a shoit lefeienco to Einhom's
clectucal method foi the examination of the
motor uctmty of the btomach must sufhce
For this pin pose he uses an ingeniously con-
tuved instiument c.illed the gastiogiaph
Although indicating all movements of the
gastric contents, it is chiefly of use as a recordei
of those gastne mo\ements which complete the
mechanical subdivision of the food and ensure
its thoiough admixtuie \\ith the gastne juice
The mcthcxl has not so far piovod of much
practical utility
Patlioloyical vattation* of (ja\tnc digestion
may be divided into secretoiy, motor, and
sensory
The vauations in secietoiy actmty may bo
cithei in the direction of met eased or of
diminished activity, and may affect one or all of
the constituents of the gastric juice Whcieas
under noimal conditions the g.tstiic mucosa only
secretes in consequence of some stimulus, in
hypeisecietiou it continues to act dining the
intervals between meals, ^and, in consequence,
the stomach is found to contain fluid even
during hungei This hypei secretion 01 gastio-
succoiihcttd may be intei nnttent 01 ch ionic, and
is usually assoc lated with moie 01 less sensoiy
disturbanee
Diminished secretion of gastne juice is found,
especially in atiophu conditions of the gastiic
mucosa, e y in adeni.i A enti leuli
Anomalies of sccietion affecting individual
f onstituents of the gastne juiee aie usually
limited to xaiiations in the quantity of hydio-
chlouc ciud piodueed, the quantity or pepsin
icmainmg fanly constant, and may manifest
them&ehes as cithei a subacidity or a hypei-
acidity of the gastne juice The total acidity
in such cases may leach t dines oi from 100 to
150 pei cent, while the acidity due to fiee
hvdiochloiic acid may amount to fSO to GO pei
cent The alterations in acidity in the chfFeient
pathological conditions affecting the stomach
(carcinoma, gastuc catauh) .11 e refeued to
undei then special he.idmgs
Diminished motoi activity of the stomach
may attee t the uiiisculaT walls of the oigan as
a \\hole, e*/ in atony of the stomach, 01 be
limited to ceit am paits, as in pylonc or cardiac
insufficiency
Inc'i eased motility may be due to increased
icsistance to the expulsion of the contents as in
pylonc stnctuie, oi it may be established to
compensate foi seeietoiy insufficiency, 01 it may
be clue to nutation, as in hypeichloihydiia, or
lastly it may be HCINOUS in otigm It may be
geiieial, .is in pen^taltic umcstof the stomach
and in \omitmg, 01 it may tike the foim of
spasmodic contiactions locahscxl to the caidiac
oi pylonc orifices
While digestion is noimally unaecompamed
by sensation, in pathological conditions the
\aiieties of sensoiy distui bance that may occiu
aie so numeious that lefeienee must be made
to the upecial aiticles on diseases ot the stomach
BILE
The wnetioii of f/ile takes place continuously,
in this respect diftcimg from the tine digestive
secietions At the present time bile is legardod
mainly as a fluid which contains ceitam cflete
pioduets destined toi excietion, some of these,
houevci, being absoibc*d by the intestine aftei
then dischaigc fiom the bile 4uct Ccrtiim
subsUiices which are insoluble in such a wateiy
solution as mine can be dissolved and so
excieted by the bile The most important
bib.ii) constituents are formed in the liver, not
376
DIGESTION AND METABOLISM
being found in the blood cither normally 01
after removal of the liver, but if the outflow
of bile be hindered, the bihaiy constituent**
appear in the blood and arc partly deposited in
different tissues, partly excieted by the kidneys,
giving the urine a biowuish-gieen coloin ]
PmmoLOdicAL ACTION — Until comparatnely j
recently it was assigned a very important iole |
in digestion , but now it is onlj legarded as ot
importance in the absoiption of fats It does
not exorcise any duvet dvteirunt action on
putrefying processes so fai as can be made out
The digestion of pioteids and carbohydiatcs is
piactically unaffected by its * ithdian.il , but
only about half the noim.il amount of iat is
absoibed, the rest being excieted in the hoces
This withdrawal of fat in the U«ces allows the
action oi putt ef action oigamsms on the pioteidh,
because the lattei become coated with fat, and
so the action of the panel eatic juice is prevented,
and decomposition ensues So long, howeAcr,
as excessive quantities of tat in the tood aie
avoided, neithei the gencial condition, e</ >
nitrogen equilibnum, nor digestion suffers It
is exceedingly difficult to study the action ot
drugs on the bile seciotion, because the flow is
such a vaiiablc one even nuclei oidmary con- |
ditions, and as a result of this the conclusions
which different nrvcstigatois have come to are
vciy contradictoiy It seems probable that no
substance, with the exception ot certain of the
bile constituents themselves, acts as a tine < hol-
ag°gu° The piessmo ot the bile in the ducts
can rise to a much gt cater height than th.it of
the blood in the portal system The tempcia-
ture of the blood in the hepatic \cin is highei
than that in the portal, showing that the cells
have been undergoing active metabolic changes ,
but of com ne this applies not only to the hiliaiy,
but also to the glycogemc function ot the hvci
MODE OF ORIGIN ui CONKTIIUBNIH — The onl) ,
bile constituent of which we know more 01 less \
dehmtely the modo ot oiigm is the bile pigment
This pigment occurs only in animals whit h con-
tain lucmoglobm in then blood It is certain
that the blood pigment is cither set fiec in the
liver from the breaking down of red blood-
corpuscles, 01 it is set free elsewheie and camed
to the liver, where it is split up into an 11 on-
holding ladicle, hfcinatin, and albumin The
former loses its iron and takes up water to form
bihrubin, the non being le tamed in the li\ei,
perhaps helping to foim haemoglobin latei
A very small quantity of iron is excreted in
organic form in the bile, not nearly sufficient to
account for the amount picseut in the haemo-
globin l>efore destruction After injection of
htemoglobm into the blood, there is an increased
production of* bihrubin , but this does not
result in an absorption and deposition ot pig-
ment until the amount becomes so great that
the bilo capillaries or smallei bile ducts become
blocked Any agents which cam break down
the red blood-corpuscles setting free htemoglobm
can produce bihrubinuna it the amount of dis-
integration be great enough to produce obstruc-
tion in the bile capillaiics On obstiuction to
the bile outflow, the resultant absoiption takes
place in the laigei bile ducts, thiough the
lymphatics into the thoracic duct Biliiubni
can be foimed fiom haemoglobin outside the
hvei, as, eg, in old blood extra\aRations,
htemorrhagic mfaicts, etc The pigment which
crystallises out undei such conditions was first of
all desciibcd by Vncho\\ as htematoidm, but it IK
now know n to be identical w ith bilu ubm There
aie many other facts whuh bring out stiongly
the intimate connection between the blood and
bile pigments Only one of these need be
lefeiied to, namely, the ioimation and excretion
in the in mo of the nnpoitant 11 on-free blood
pigment, hff}matoporphyiin,mceitam conditions,
ty aftei sulphonal poisoning (w "Hjemato-
porphjrm") This pigment is isomenc with
i)iliiubm The chief pigment in human bile m
not, however, biliiubin, »mt bihverdm, which
gives the green colour *> tho fresh bihaiy
seciction It is rapidly led need in the intestine,
fiom the action of bacteria, into hjdiobilnubm
.ind dernatncs of that pigment The souico of
the other constituents of thc> bile has not been
so well made out CViofottow, a constituent
piobably ot eveiy In ing animal cell, is, like the-
bile pigment, an t-ftete pioduct It is denved
tiom the metabolism of the cell piotoplasm, and
is distinguished by the icsistauce which it ofh'M
to further decomposition, and also by its tend-
ency to foim gall stones With legaid to the
srt/£« «/ the bile acnlt>, gl) ecu holie and tun ocholic,
they aie the only bodies which can undoubtedly
act as cholagogues, undei going absoiptiou by
the intestinal mucous mcmbiaiu* aftei their
exeietion into the durxlenum Theie can be no
doubt, howe>ei, that this absoiption takes place,
not in the duodenum, but in the jejunum and
ileum As these acids undeigo partial absoiption,
alterations in the amount ot pioteid in tho iood
do not aftcct to any extent their excietion in
the bile Thus, aftei iiici easing the amount
ot pioteid in the food, the salts ot the bile aeids
aie barely increased at all in the bile Their
absorption may take place directly into the
blood- vessels of the intestinal mucosa, although
probably the lymphatics fatm the main channel.
These salts piobably play an important pint in
aiding the absoiption of other substances by the
intestine — foi example, soaps of the alkaline
earths and fats The other constituents of tho-
bile arc not of so much impoitance Tho Ixxly
which lends the peculiar stringy consistence to
the bile, namely, mucin, is secreted by the gall
bladder and larger bile ducts In man it is a
tiue niucm, but in the o\ it is supposed to be
a nucleo-albumin There are also present in
the bile small quantities of fat, feet then, and
DIGESTION AND METABOLISM
377
The amount secreted can only be estimated in
cases of biliary fistula, and such estimations are
not reliable, because a certain amount of the
bile is normally absorbed by the intestine, and
acts upon tbe biliary function of the liver It
it bo then withdrawn by moans of a fastula,
this natural cholagoguc is removed, and so less
IH excreted than what would normally be the
case The quantity also vanes with the amount
of water taken and thn natuie of the diet,
animal food increasing it to the most maikcd
extent The maximum of flow occurs some
hours aftci food has been taken , the luigei the
meal, the longer the inters al befoic the maMmum
appears Exceedingly little is known as to the
action of the nervous system on bile secretion
There seem to be ceitamly no tine secretory
nerves, but the secretion may be allotted by
vaso-motor influences If the blood of the poital
vein be allowed to paws directly into the nifciior
eava without passing through the luei, the
secietion of bile still goes on, and the same
holds good aftei obstruction of the hepatic
arteiy After splanchnic stimulation thcio is
a diminished fkm, with contraction of portal
vessels, while after section the opposite occurs
The expulsive action of the gall bladdei and
larger bile ducts is undci the influence of the
nervous system, pcnstaltu waves of conti action,
similar to the intestinal ones, otcmimg along
their smooth musiulai tibies These may «ilso
be stimulated lefloxly fiom the gastric mucous
membrane The remoxal of bile fiom the hvei
through the diuts is caused by the back picssuie
of the newly ioimcd secietion. .uid also fiom
the picssuio on the Inei dunng inspiration
P \ nioT.or,ir VL Ai TEHAIIONS — It may undergo
pathological a/fetation*, of which the duet are
due to obsti notion to the bile outflow \\ hen the
pigments and salts ot the bile acids are ab-
sorbed, and the fluid left in the dilated channels
is often found to contain only tiaces of the tine
constituents with an excess of mucin (we
"Jaundice")
Undci ccitain conditions, the natuie of which
we do not yet know, <jall vtonev ma) form in
the ducts These vaiy in si/e, form, and chemi-
cal composition There are two important foi ms
met with in man, cholcsteim and pigment chalk
stones, the foimei being by fai the more fic-
quent They are white or faintly yellow in
colour, and are specially characterised by their
low specific gravity, which is less than that of
watci Absolutely puie cholcstcrin stones are
rare, theie being usually a bihrubm chalk nucleus
around which the cholestcim has ciy stall ised
out The pigment stones arc much more easily
broken down by pi ensure than the others, and
are usually much smaller and heavier They
very often contain traces of copper and a larger
or smaller quantity of other bile pigments in
addition to bihrubm, t.q biluerdin When
numbers of gall stones have collected in the
ducts, they present a faceted appearance, owing
to the pressuie to which they have been sub-
jected Veiy often small stones or giavel, com-
posed of calcium caibonatc tinted with bilnubm,
ate passed The occurrence of traces of heavy
metals, ey Ca, Zn, As, emphasises the import-
ance of the bile as a medium for excretion
With regard to the cause? leading to the forma
tion of gall stones, it has been suinnsed that in
the case of cholestenn ones, two factois ma}
have placed a part, vi/. insufficiency of bile
salts to keep the cholcsteim in solution, or
excessive formation of the latter The most
piohable cause leading to the formation of both
kinds of calculi is obstruction to the bile out-
flow owing to catanhal conditions of the ducts,
when the excessi>e secietion of mucus 01 the
shedding ot epithelium may at least aid in
then production
I'A\< REA1 K' SK KKTION — NTAI LRK AND METHOD
OF SEfRETioN — The most impoitaut changes
\\hich the food-stuff s undergo aie the lesult of
the action of the jiancittitu jwrr The acid
ihjme is giadually neutiahsed by the clear
alkaline fluid which is secieted by the cells
lining the panel eatic acini, and which is poured
into the duodenum through Winding's duct
If the fluid be obtained fiom a fistula, it is
found at the outset to have a specific gnuity ot
about 1 03 , but, aftci some time has elapsed,
it becomes poorer in pioteids and of lower
specific giavity In cainivora and ommvora
the secietion is not a continuous one During
activity the cells of the panel ea tic acini undergo
distnu t alterations Thus at the beginning of
digestion the gianulcs of zunogen gradually
disappear fiom the innci /one until the whole
cell at last appeals cleai Then the granules
aie again foimed in the inuci pait, the outer
/one acting as the storehouse foi the material
out of winch the /)mogen is formed These
/>mogen gianules are only transformed into
the actuc ferment after the gland has been
exposed to the .in for some tune, or after it has
been subjected to the action of w eak alkalies or
.uids The Amount of the juice secreted in
twenty -foui hours is impossible to estimate
accurately, as in cases ot fistula it undergoes
marked alterations, rapidly also becoming poorer
in solids As in other similar secretory pro-
< esses, the secretion is accompanied with vascular
dilatation
NERNOUH MECHANISM — If the vagus be stimu-
lated, there is an increase in the amount secreted,
the fluid also being thick in consistence , while,
if this neive be cut, and its central end stimu-
lated, the flow is greatly diminished, or may be
stopped altogether A i at her important cause
of stoppage of secretion is vorftiting, hero also
the influence ot the vagus making itself felt
It is an interesting fact that the acid chyme, on
coming into contact with the duodenal mucous
membrane, causes an me reased pancreatic secre-
378
DIGESTION AND METABOLISM
tion, and this brings about neutralisation, while
alkalies have the opposite effect This icflev
secretion persists even after the vagi and sym-
pathetic have been cut, its occurrence being
then probably duo to the presence of a local
centre perhaps in the neighbourhood of the
pylorus The maximum flow occurs about thice
hours after food has been taken, then sinks for
about the following four hours, when it may
again use The greatei the flow, the pooroi is
the juice in solids
ACTION or "IHK KVHYMKS — The ferment* in
t/te pancreatic jut re aie lour in number, the most
important one being ?»#/*&*?<, which acts upon
proteuls, tiaiisfoimmg them into more soluble
bodies
Unlike pepsin, it acts best in a weakly alka-
line solution, although it is also active in neutial
or faintly acid ones Still even \vith weak
organic acids, although at the outset the action
IH almost as marked as in slightly alkaline
media, th^ ferment is slowly destioyed, dis-
appeating, howevci, much moie lapidly with
weak inorganic acid solutions Thus it is use-
less giving such preparations as pancieatm bv
mouth, because trjpsin w lapidly de> trowed by
the acid gastric juice The first action which
it exercises on proteids is simply a solvent one,
and it is doubtful whether any alkali-albumin is
found or not. The digestion passes so lapidh
through the stage of pnmaiy alhumoscs that it
is often difficult to detect their piesence, but
deuteio-albumose (a secondary one) is formed
in Luge quantity, and then peptone makes its
appearance. But the most chaiacteriHtic fcatuic,
from the chemical standpoint at least, in tryptiu
digestion is the fuithci decomposition of the
peptone Until recently it \vas believed that
all the peptone did not undergo decomposition,
but that a pait was icsistant, this being teimcd
autipeptone, while the rest, which was split up
into amido-aculs (such as leucin, tyiosm, and
aspartic acid), ammonia, etc , was termed liemi-
peptone Siegfried regarded antipeptonc as
identical with an acid winch he found in paired
combination in muscle and milk, namely, tarnii
acid , but it seems unlikely that this is the case,
as Kossel, Kutscher, and others have shown
that Kuhne's antipeptonc is really a mixtuic
containing ceitam bases, called the hexone
bases (lysm, histidni, and argmm) These bodies
are only foimed aftei very pioloiiged digestion
The point of impoitance is that, in .ill probability,
if only digestion be continued long enough,
all the peptone can be bioken down Now,
although this is true for aitificial tryptic diges-
tion, the action is a much moie limited one in
the intestine, very little leucin and tyrosin ever
being formed under noimal conditions In fact,
it is piobablo that the pincroatic juice is mainly
required to lendei the piotcids soluble and
ready for absorption in cases where such large
quantities have been taken that, if this action
did not take place, a great loss of proteid would
icsult, this material undergoing decomposition
in the lower parts of the intestinal canal. As
w e shall describe more fully latei, one is com-
pelled to admit that even the transformation
into alhumoscs and peptones is not absolutely
essential because the forerunners of these (soluble
albumins and alhummatcs) aie themselves cap-
able of absoiption by the intestinal mucosa
The pioducts of a pancreatic digestion easily
nuclei go putrefaction, and hence in aitifieial
digestive fluids such an agent as thymol or
chloiofoim lequncs to be added In addition
to the substances mentioned above, a chromogcn
teimcd trvptophan, the natuie oi which has not
yet been "fully made out, is formed about the
time that the anudo-aeids appear A small
amount of hue ammonia also appeals dm ing
digestion Such is \eij shortly the nature of
the hydiolytic decomposition of a simple pio-
teid under tryptic digestion Complex piotcids
aie also moie encigotically attacked bj tiypsm
than pepsin Thus miclfo- albumins have not
only their albuminous constituent easily biokcu
down, but the icsistant nnclcin ladicle is also
slowly dissolved
Thcie aie in addition thiee othei cn/ymes
which occur in the pancicatic juice, an amjlo-
lytic, a fat- splitting, and a milk-cuidling one
The amylolytu feimcnt, so fax as we at piescnt
know, acts on the polysaccharidcs in the same
way as ptyalm Thus starch and glycogen
undcigo hydratiou and aie split up into the
dextrms, which weie described undoi sahvaiy
digestion, and maltose The amount of the
final pioduct, maltose, depends on the, lelativc
quantities of en/ymo and i>olysaichaiide The
monosaccharides undcigo no altciation, but aio
absorbed without alteration, while cellulose is
not affected by the juico
The action of the pa/icieatu juice on fat* MA
moie complex one The acid chyme is neutial-
ised by the bile, pancieatic juice, and the secie-
tions fiom the intestinal glands, and then, if
fatty acids be present, emulsification of fats can
at once take place , but the fat-splitting ferment
assists in this action, setting free fatty acids
from the neutial fats This fat-splitting action
docs not require to bo a vciy maikcd one,
beeause a very small quantity of free fatty acid
is able, in the form of a soap, to emulsify a
large quantity of fat Uitei on, the mode of
absoiption of the emulsion will be icf erred to
Lecithin is also split up by this ferment Bile
seems to assist this ferment in its action. Like
all other enzymes, it is easily destroyed by
boiling, and the same occurs if the gland be
exposed to the air for a short time, as in the
artificial prepaiation of pancreatic extracts
The nulk-curdliwt ferment of the juice seems
to be identical with rcnimi, only its mode of
action has not been so carefully worked out as
that of the feiment derived fiom the stomach.
DIGESTION AND METABOLISM
379
I'ATHOIXXHCAL ALTERATIONS in the juico have
not been much investigated In certain inflam-
matory conditions affecting the pancreas the
juice secictcd is thin and inactive, and in othci
pathological conditions there may be a stoppage
oi the flow, due to the ducts being blocked up
The pancreas, however, plays an nnpoitant part
in the metabolism of glucose, AN Inch may be
icfeired to here It the gland be remo\ed
cntiiely from dogs, diabetes of a severe type at
once sets in, and death ensues in a shoit time ,
but if a small portion lie left, so long as this
does not undcigo atiophy, only tr.ues of glucose
appear in the mine As soon as the lei naming
piece atrophies maikcd glycosuiia sets in, and
within a few \vceks 01 months the animal dies
In such cases, glucose is cxcieted even when no
tarbohydiate is given in the food, and if any be
given by the mouth, it M wholly excreted in
the ut me The blood in such cases shows a
high peicentago of glucose — 0 3-0 3 per cent
It is important to note that mere withdiawal of
the June fioin the intestine does not pioduce
diabetes, noi does ligature of the paiuieatic
vein At piesent we do not know in \\hat way
the pamicas exeiuses an influence on the meta-
bolism oi glucose In a few cases of diabetes
the panci eas has, on post-moitem examination,
been found to l>c ati opined, or otheiwise patho-
logically alteied (we " Diabetes")
INIKSHNM, SKCRKTION. — The succus cnteiicus
is secieted by Liebeikuhn's glands of the small
and huge intestines It is obtained usually
fiom fistulftj (Thny-Vella), when a piece of
small intestine, about 50 un long, has been
lescctcd with the mesentery attached and the
uppei and lower openings sewed into the ab-
dominal \\all
It is .1 clear yellow fluid of maikedly alkaline
reaction, < ontammg usually a tan lv large quantity
of solids, although the amount of these \ancs very
much With regai d to the tn.i/me\ present there
is a gieat deal of contiadictoiy evidence It
booms most likely tint it contains no feiment
which <u ts on protcids 01 fat , but it certainly
contains an inveitmg ferment, and \eiy piobably
more than one In some animals the secietion
appeals to be a continuous one, in others it only
occius after stimulation of the mucous membiane
Experimentally one may use cither mechanical,
chemical, or electucal stimuli Usually the
amount secieted begins to mciease about one
hour aftei food, and gradually rises to about the
third hour, when it falls again Veiy little is
known as to nrtvoti* influences exerted on this
seciotion If all the nerves, passing to such an
intestinal loop as has been described above, be
cut, fluid accumulates in the sac Stimulation
or section of the vagi seems to have no effect
With legal d to the action of the juice on the
food, there seems always to be a slight diastatic
action, starch being con\erted into maltose , but
more important is the inverting action trans-
forming maltose into glucose and cane-sugai into
glucose and levulose Lactose does not seem to
be inverted by the juice, although it may be in
its passage through the intestinal mucosa The
inverting action takes place in the presence of
antiseptics, but js destioycd by boiling
In the lowet jtart of the small inteitine, where
putrefactive organisms possess a suitable slightly
alkaline medium, the pioteids undeigo changes
which aie .it the outset similar to those pioduced
by the gastric and pancreatic secretions That
is to bu\, insoluble albumins aie tiansfoimed
slowl> into soluble hums (alhumoses and pep-
tones), and in all piobabilitv this action is due
to en/yrncs secieted by the bacteria These
organisms do not attack unaltered albumin in
tin npjKH pait of the intestine, because there
thev have a supply of albumoses and peptones
leady ioi assimilation Recently an elaborate
scties ot experiments lias been canied out m
ordei to distovei whethei micro-oiganisms aie
necessai y m intestinal digestion, and it has been
shown that guinea-pigs \v Inch had been born in
a stenle medium could h\e theie even when
then food was absolutely fiec horn oigamsnib
This of (ouisu does not touch the question as to
whether bacteria may not be of use in aiding
the action of the intestinal enzymes And again
there aie substances present in the usual diet
which aie unaffected by the other en/jmes, but
aie dissolved bybacteii.il action, e i/ celluloses
These micio-oigamsms can also break down
pioteids along different lines from the pioteolxtic
en/ymes In the hist place the aromatic radicle
may undergo a \ariety oi decompositions Thus
t} rosin is not only formed itseli, but fiom it
other benzol der natives aie obtained by reduc-
tion oi oxidation, ending with the production of
phenol, and m addition there are produced
aromatic substances of a different order which
are not iound in ordinary tiyptic digestion,
namely, indol, skatol, and denvativcs of these
In the second place, bodies of the fatty series
aie formed often in faiily huge quantity, <•</.
leucin and volatile latty acids such as butyric,
viler i.mit, and caproic acids There is no fiee
oxygen in the intestine, owing to the con-
tinual formation of hydrogen and sulphuretted
hydiogon fiom bacterial action, so that .my
parasites which aie present must get it indnectly
from the capillaiy blood ot the inucosa by keep-
ing as dose as possible to the intestinal wall
The amount of oxygen which thev lequire is
veiy small
Ptoiiuune* -Theic aie also bodies of a basic
nature domed fiom the decomposition of proterds
which normally aio not formed in the intestine
during life These Ixxlies, teimed ptomaines,
do not appear until about three Hays atter death
They aie formed also when the intestinal bacteria
aie giown m different culture media As a rule
these bodies, which belong usually to the fatty
series, arc not veiy poisonous if they be pro
380
DIGESTION AND METABOLISM
duced rapidly after death, but those which
make their appearance later are often extremely
poisonous even m minute doses. The best
examples of the non-poisonous class are cadavenn
and putrescin, while neurm, derived from the
decomposition of lecithin, is the best example ot
the poisonous series This body is formed, un-
like the ordmaiy poisonous ptomaines, com-
paratively rapidly after death, usually about
the thud day. One I must bear m mind the
possibility of the formation ot Mich Ixxlies in
tinned meats and decomposing flesh of any kind,
and also that similar bodies may be formed
even during life m ccitain animals, c g mussels
(set "Diet") It is a comparatively rare oc-
currence to meet with the formation of those
bodies undci pathological conditions m the
organism, but they do occur in the fceces in
cholcia, especially putiescin «uid cadavenn The
pi imary poisonous pioductsof bactciia are usually
of the nature of globulins 01 albumoses
Not only aie proteids acted upon by nucio-
orgamsms m tho lower paits of the intestinal
canal, but tats aie split up into glycerine and
fatty acids, and nubohydiates undergo nmiufold
fermentations or arc simply hydratod So long
as there are caibohydiatcs present in the small
intestine which hme. tiot undeigone fermenta-
tion, the pioteids aie protected fiom the action
of micio-orgarnsms Thus a milk diet, from the
prc&onco of lactose, pic\ents decomposition ot
proteids owing to the foiination of lactic acid
Tho influence which nnabsorbed fats exercise on
the putrefaction of proteids has aheady been
referred to In tho comparatively short small
intestine of cainivoiu, and en en m that of
omnivora, vciy little putrefaction is set up
compared to that occuinng in the largo intestine
Putrefaction in both small and laigo intestines
is limited, however, to a compaiatncly small
amount of the food-stuffs present, because, in
the first place, micio- organisms, by rendoiinu:
these substances more soluble, transform them
into matciial which is more easily absorbed, and
when they do break down proteids tuithei, they
form small quantities of substances, such as
phenol, which check putiefaction, while in the
last place, owing to the gieat absorption of watei
m tho laige intestine, the conditions undei which
the bacteria glow are tendered less suitable.
Before taking up the subject of intestinal move-
ments, etc, it is necessary to icfer shortly to
the modes of absorption of the digested material,
and also to the nature of its transmission through
the organism
ABSORPTION — The put which the gastnc
mucous membianc plays in absorption is still
doubtful Although very little water is absorbed,
a fairly large quantity of soluble salts, albumose,
sugar, alcohol, etc , is taken up , but the main
channel of absorption is through the intestinal
mucosa. Tho amount of a food-stuff absorbed
is independent of its osmotic equivalent
ABSORPTION AND METABOLISM 01? PHOTKIDS —
Although the absorption of proteids is rendered
an easier and more rapid process by their
peptomsation, there can be no doubt that
soluble albuminous substances, Mich as syn-
tomn and other albummates, can be absorbed
without undergoing fuither alteiation Modern
treatment by rectal feeding is bawd on this fact,
tor in the large intestine tho transfoi mation of
proteids into albutnoses and peptones takes place
only to a slight extent, not nearly sufficient to
account foi the f.ict that patients can by this
means bo kept m nitiogcn equilibrium Tlus
is tine not only tor the absoiption, but also toi
tho assimilation ot soluble albuminous substances
Thus one can iniect the blood-serum of anothri
animal into tho veins of a dog without albumin
afterwaids appearing in the urine The ionim-
tiou of IdTge quantities of albumose or peptone
seems in fact to be deleterious, as the intestm.il
mucosa is apt to sufler fiom excessive stimula-
tion When albumoses 01 peptones sue absoibcd,
they are not carried as such to the tissues, but
undergo pol^meiisatum into albumins in the
intestinal mucosa
Neither albumosis noi peptones aie present
in tho blood at any time dining digestion, nor
aie they stoicd up in the intestinal wall, and
yet if they be allowed to lie in a separated
intestinal loop they rapidly disappeai They
must then undergo some alteiation in the-
intestinal wall, and it the blood in the mesen-
tenc or poital vein be examined after a meal
rich in pioteids, it is tound to be much richer
in albumins than befoie digestion, while the
lymph in the thoiacic duct S!IOA\S no alteration
in its percentage of p rote id Ligature of the
thoracic duct does not prevent the absoiption
ot pioteid, nor the subsequent use in the excre-
tion ot mtiopcn in the urine These facts go to
prmu that the absorbed albumoses aie trans-
formed into albumins, and that the channels
into which the latter pass are tin1 blood and not
the lymph xcsscls The means by which this
transformation has been brought about arc un-
known The leucocytes certainly do not seem
to take up the albumose and peptone and trans-
foi m them into albumin, because no evidence
has been brought forward that they aie capable
of offocting such a transformation Tho great
mass of absorbed proteid seems to act as a source
of energy without being taken up by the tissues,
and organised, although a small amount must
supply the place of the cell pioteids, which arc
always undergoing degeneration The amount
of nitrogen excreted during tho day in the healthy
adult is equal to tho amount absorbed m that
period — that is to say, tho organism breaks down
the same amount of proteid that it absorbs, a
condition referred to as nitroyen equilibrium
The small amount of nitrogenous waste products
which tho tissue proteids furnish to the blood
when they break down is balanced by tho amount
DIGESTION AND METABOLISM
381
of protoid taken up from the blood (en dilating
proteid) for the regeneration of the tissues It
is exceedingly difficult— one may say impossible
— at present to follow out the chaug<' * ' '
proteids undergo in their decomposition me
end-pi od nets of then metabolism .tie well known,
but the first katabohc changes which they under-
go in the cell piotoplasm we can only surmise
llieti is the principal nitrogenous end-product in
mammals, while in birds unc acid takes its place
hi both crises ammonia salts play mi important
part as forerunnci s of these end-products When
blood containing ammonium salts of formic, acetic,
01 lactic acid circulates through a fre&h Irvci, urea
is fanned in appreciable quantity Heic, in .ill
probability by a piocess of oxidation and syn-
thesis, ammonium caibonatc is ioimcd, then, b>
loss of watei, ammonium (arbamate, and finally
uroa It is piobable that one ot the most im-
portant non nitrogenous decoii position pioducts
ot i>rotoul nK't,t holism is saieolactic acid, which
becomes distinctly me leased in the blood aftei
pioteids have been taken in the food, and falls
correspondingly in conditions of hunger This
acid seems to be ioimcd m most oigans, e</
lungs, kidneys, etc, when blood is tiaiisfused
thiough them, <iud its pei contact- m muscle
uses diinng exercise Its ammonium salt is
tiansfoimod into uica in the h\ei If oxidation
processes be hmdcied in «my \\ay, theie is an
UK i eased foim.itiou and excretion of this acid
There aio many othoi dem«iti\es oi piotoid
metabolism, et/ glycocoll, acetone, etc, which
may appeal in the urine as such 01 in combina-
tion with other substances (s«- " Vime'') The
sulphur and phosphorus present m ceitain
pioteids aie m laige pait oxidised to then full
extent and excieted as simple 01 panod sulphates
and as phosphates (see " L rule ")
AiwoiirnoN AND MEIAHOIISM OF CAUHO-
HYiWA'iEs — Undei (iidiiituy conditions the
glucose is only taken up by the blood capil-
lanes, but if there be a gre.it excess of sngii
in the intestine, some may also pass into the
lacteals Kven aitci a diet comparatively i u h
in carbohydiates, the amount of glucose in the
lymph flowing fiorn the thoracic duct shows no
increase, while the blood m the poital vein
shows a use fiom the noimal, Oil per cent, to
about 0 4 per cent In oulci to pi event the
loss of such an easily diffusible substance, the
hvci acts as a stoi chouse for the glucose, trans-
forming it hist of all into a less soluble form,
glycogen, and giving it out again to the blood
in the foim of glucose when the pciccntagu of
the lattci in the blood tends to fall below
normal By excluding carbohydrates from the
diet one can gradually lower the amount of
glycogen m the liver , while if one inject glucose
into the blood of an animal whose liver has been
rendered free from glycogen, the percentage of
the latter m the liver can gradually be raised
It seems probable that these transformations of
glucose into glycogen and glyc«»geu into glucose
are the results of the activity of the liver cells,
and not oi the action of an en/yme produced by
the latter The muscles and many other tissues
can effect this dchyhation and polymerisation
of glucose into glycogen as well as the liver
In fact, glycogen seems to be picsent at least in
evciy living cell .it some stage or other in its
lifc-histoiy The muj-elcs seem to store glyco-
gen before the hvci docs, and they ccitamly
ictam it longer Thus it is ;>os^ible to exhaust
the livei while the m.iscles still contain a fairly
large quantity In frogs the muscles can also
*-loic up glycogen even \\hcn the liver has been
rcmoMMi One may say that appioximately 150
}. aminc" oi 1he sugar that has been absoibcd
by th> intestine are stored up as glycogen m
tho li\u and a slightly larger quantity in the
lauvlfs and othei tissues of tho body When
a lu«;ei quantity ot caibohydrate is absorbed,
then the liver and muscles would in .ill piob-
ability be uiublc to conveit the excess into
glyrogeu, and the percentage of gltu ose in the
blood might use to siuh a height (o\er 0 3 per
cent) that the kidneys could no longer retain it,
and the condition of glycosuna would result
Hut it is probable that there is another icason
foi temporary alimentary glycosuna in healthy
mdiMcluals hi cases where huge quantities
of caibohvdiatc have been taken with a free
supply ot liquids, absorption ma} take place by
way of the lacteals, and the sugai may i oath the
genuial circulation without passing through the
li\cr The peiccutagc in the blood in such a
case may be so high that temjKnary glycosuna
lesults When veiy laige quantities of disac-
(haiules, such as cane or milk sugai, ate taken,
some may escape imcision in the intestine and
be e\ci cted unchanged in the urine One must
lemembci, however, that the bowels may act a*"
.1 safety-\ahc tor the remo\al ot the excess ol
sugai, diairhwa being set up by the intestinal
nutation Pioteids may also act as a source oi
gly(ogen, so that even when no caibohydrate"
are given in tho food, a Iner which has been
leiulered iiee from glyeogen can stoic it up
again if suthc lent proteid be given in the food
It is impoitant also to remember that the
glycogeu may accumulate in the h\ei from the
action of substances which piounit the liver
cells tiansfoimmg it into glucose, e </ gljceiine,
antipyrm, chloral, etc Imersion of the disac-
chandes is necessary befoie they can be trans-
formed into glycogen The sugar circulating
in the blood is noimally oxidised by tho tissues,
furnishing finally carbonic acid and watei, and
in this action the muscles play an important
part, as the glucose is the chief souicc of mus
culai encigy When this action of tho tissues
does not come into play, the percentage of
glucose in the blood rises until the kidneys can
no longer icfrain from excreting it (set
"Diabetes") The influence of the nervous
382
DIGESTION AND METABOLISM
system on the glycogemo foimatiou and tians-
formation in the liver is probably a vaso-motor
one Thus, after punctun? of the floor of the
fourth ventricle, poisoning with nitrate of .uuyl,
curaii, etc , the resultant glycosuna is due to
an increased transformation of glycogeu into
glucose The influence of tho panci'*as on
tho metabolism of glucose has already been
referred to
ABSOHPTION AND MEIAHOLISM OF FAIH — This
can take place to Home extent even \vhen no
pancreatic juice or bile is allowed to act on the
chyme , but lx>th of these aie of great impott-
auce in <udmg absoiption In nuny cases the
mixed contents of tho small intestine arc acid
in reaction (as in dogs), and \et cmulsification
of the fats can take place if tho panuieatic ]iucc
have free access It is not necessary that theie
should l)o sufficient alkali piesent to neutiahse
all the fatty acids, because not only is a small
amount of soluble soap able to emulsify a fanly
large quantity of these a< ids, but m addition
the salts of the bile acids can easily dissolve
them and so aid absoiption Soaps and tatty
acids pass partly into the blood capillaries,
paitly into the lymphatics, but they aic trans-
foimed into f.its during their passage thioiigh
tho intestinal mucosa, fur aftei they have be< n
given in the food, the lymph m the thoiauc
duct contains only fats
Theie is no reason foi believing at present
that tho absoiption of fats takes place entirely,
or even most laigely, in the iorm of solutions of
soaps, and not as an emulsion of soaps, free
fatty acids, and fats After absorption of fat,
the cytoplasm of the columnar cells of the
intestinal mucosa is found ciowdcd with iat
globules, while none aie to l>e seen in the
striated hem This is no proof, however, that
the fat has not passed through in the form of
an emulsion, although it has been regarded as
supporting the view that the fats aie absorbed
in the form of solutions of the soaps, and that
the latter undeigo m the columnai cells syn-
thesis with glyceiinc to form fats Undoubtedly
the contraction of the smooth musciiLu strands
m the vilh aids at least tho passage of the chyle
through tho lacteals Fats of low -melting point
are moic rapidly and completely absorbed than
those which melt at a higher tempciaturc In
many cases when fats foicign to the animal
experimented upon aie absorbed, they are de-
posited unaltoicd in the tissues , but in man
the absorbed fats are not necessarily deposited
m the form m which they were taken in, being
usually transformed into the ordinary mixed
fats of the tissues There can be no doubt that
the synthesis of fatty acids and glycerine into
fats can and dees take place in the columnar
cells of the intestinal mucosa but, as has
already been said, this docs not exclude tho
other method of fat absorption — emulsificatiou
Carbohydrates and pioteids may also act as
souiccs of fat, but the pioot of this cannot be
given in this article (tee "Diet") The fats
are deposited m vaiious parts of the body,
while a large amount, by oxidation to < arbonic
acid and \vater, sets free energy which may
take tho form of eithei woik or heat Tho
nature of fatty degenerations and infiltrations
of oigans will bo referred to under the special
pathological headings
AHsourrioNOF PuTHEFArnoi* PRODUCTS — The
products oi putrefaction formed in the lower
paits of the intestin.il canal may also be ab-
soibcd This is especially noticeable in cases
of ititcstm.il obstruction, when phenol, mdol,
skatol, etc , aie absoibed, oxidised in the tissues,
and exiietediu combination with sulphuncacid
iNiEsiiNAh MOVEMENTS — It is exceedingly
difficult to study the noimal peristaltic mo\e-
ments of the small and l.iige intestines, because
on exposing them to the air there is a maiked
diminution in the penstalsis They have been
usually studied w hen the intestines have been
suiiounded Ivy a warm saline solution One
can then peiceive that peustalsis is moie
maiked m the small than in the Luge intestine,
aiul that it takes place noimally in thodnection
tow aids the anus, the movements consisting oi
ring-like conti actions passing alonu m the form
of waves The collect direction is maintained
by the tians\cise folds of tho intestinal uuicosa
acting as \alves, the well-marked fold at the
place of entrance oi the small intestine into
the ctecum preventing legurgitation Antipcu-
staltic movements, such as occur m ttecal vomit-
ing, are not to be seen under normal conditions
The fact that this penstalsis piocccds in one
diicction only, and that slowly, proves that it
must be undei the influence ot the nervous
system, and yet it persi-sts aftei sec tion of the
mesentciic ncr\cs, being also visible in separated
intestinal loops It is probable, therefoie, that
theie are local c en ties piesent in the intestinal
wall Tho neives passing to the intestine act
«us icgulatois of the movement, piobably affect-
ing these local centies Thus stimulation of
the \agus increases the rapidity or amplitude
of the contractions, w lule splanchnic stimulation
produces slowing of the peristalsis If indiffer-
ent fluids be en culated thiough the vessels of a
detached loop of intestine, it remains at rest ,
but, \\hencvei the circulation stops, the loop
shows periodic contractions The explanation
of this is that in the intestinal wall substances
ate foimed which act as excitants to contrac-
tion, and hence their removal pioduces rest
The contraction of intestinal blood-vessels pro-
duced by splanchnic stimulation probably causes
diminished peristalsis fiom the diminution in the
amount of circulating blood which contains the
stimulating substances There is probably a i eflex
ncivous mechanism between stomach and duo-
denum, because, shortly before tho pylorus opens,
tho duodenum, which was previously at rest,
DIGESTION AND METABOLISM
383
begins to contract Tho following conditions
also affect intestinal peristalsis
1 Alterations in temper atuie — On exposing
the intestines to a temperature below 7° C
peristaltic movements stop, while on laismg the
temperatuie they increase At 39° C peri-
stalsis m the labbit's intestine ceases, begin-
ning again when the temperatuie is laiscd to
42° ('
2 Effects of food and dunk —About fifteen
minutes aftei food 01 after a dunk of cold
water penstalsis begins, while dining the nicrht
the movements are maikcdly diminished
3 jK/ect of di wjs — < )pium and ati opine para-
lyse the action of vagus, and so hmdei peri-
stalsis , while nicotine, both aftei injection into
a blood-vessel and into the lumen of the intes-
tine, produces mueased coiiti.u tions Potassium
and sodium salts also produce contractions,
the former local, the latter moic general in
chaiactcr
4 Actum of intent inn/ content** —The bile and
the intestinal gases inciease pciist.il sis
RtrKtt — The faeces lontani the undigested
icsidues of food-stutts, decomposition products,
such as indol, foimed in the inteHtine, material
setreted 01 shed by the passages through which
the food has passed, and micio-oigamsms oi
different kinds \s a mle then icaction is and,
though it maybe neutial 01 alkaline, and then con-
sistence also vanes gieatfy at < oidmg to the natine
of the food and the tune spent in the intestinal
canal The food may act upon the charactei
oi thefccccs, eithei dim tl) fioin its own composi-
tion, 01 horn its effect upon the gland secretions
w hi( h ai e poured into the ( .inal, ot iiom its ac tion
on intestinal peristalsis Thus a vegetable
diet, from the high peicentajio of indigestible
mateiial and ot watci, and fiom the stimulant
.ution of the insoluble cellulose on intestinal
peristalsis, produces exueta which aio ihaiae-
teiiscd by their fluid consistent e, iichness in
tot<il solids, and, as a mle, poverty in colouring
material Owing to the short peiiod th.it the
material is allowed to ho in the (anil, t eduction
processes do not take place to the same extent
as aftei a flesh diet If the vegetable diet be
nch m non, the f races are much darkei in
colour The daik coloiu after flesh diet is due
to the piescnce of h.ematm or bodies derived
fiom it (ferrous sulphide, etc ), and also to
reduced bile pigments or bodies derived fioni
them Under a nn\cd diet about 130 giammcs
are excreted in twenty-four houis The most
important gases picsent aio mtiogen, hydrogen,
carbonic acid, sulphuretted hydrogen, and
methane Faeces can be foimed in a separated
loop ot intestine, and also in the intestinal canal
of starving animals oven when bile has not been
allowed to enter the intestine The excreta are
formed m such cases from the shedding of
epithelium and the subsequent decomposition of
such organic material by bacteria Different
bactciia mav be found in the faeces, e </ putie-
faction and fei mentation oigamsms and bacillus
coh communis
DErwA'iioN — Although the act is a icflcx
one, caincd out through a centie in the spinal
cold, it is laigely influenced by the will In
man this centie is situated in the lumbai legion
of the cord The pressure of the accumulated
fteces in the lectum causes, by leflex action
through the centie, relaxation of the sphmctei,
while UK leased intestinal pcnstalhis is also set
up In voluntary defecation, the act is staitcd
by a full inspiration, dosutc of the glottis and
fixation of the diaphiagm, followed by contrac-
tion oi the abdominal muscles and lovatoi am
the latter in tins \\a) exerting picsMiie on the
lectum while the tension of the pelvic fascia
ofteis tfie rt 41111 ed resistance I>y an efloit of
the will the act n.uy, up to a ceitain point, be
inhibited tsptually by me leasing the contrac-
tion of the sphincter l'mgat,i\cs may uct in
different wavs The activity of salines depends
upon th< ir endosmotu equivalent, producing a
letention oi water m the intestine Thus if
salines be injected into the blood-vessels, consti-
pation results Some again act by inci easing
the amount of the intestinal scuctions, while
others act by inci easing the rapidity or
strength of the intestinal i on ti actions (*te
"Constipation ")
Digital. — Belonging to the fingers 01
toes 01 performed by the fingeis, eg du/ital
n<rve<> (vee DLI-OUMITIES, Metatatudfjia, Neur-
;/ts), diqittil eranunatiom (see <T\NECOLOOY,
DIAUXOSIH IN, Vm/tnal fir animation)
Digltalein and Digitalin. fre
DKJITALIH
Digitalis. «SV? al^> ULAIU, MYOCAR-
DIUM AND ENDOCARDIUM (Tteatment, Afeduinal);
PHARMACOLOGY , PuLsciimiNu , SPASM ( Vanetoe*,
7Tojw), TOXICOLOGY (Alkaloids and Yegitablc
/'oiAOUn, Foxtjlove) — The dried leaves of the
puiple foxglove, Digitals 2^uijmttat contain the
following pnnciples — 1 Diyitojrm, the most
powerful, insoluble in water, soluble in alcohol.
Y^sf--^-^ gr 2 Diyitalin, the next in
powei, sparingly soluble in water Dose— ^a-
ioff & subcutaneous^ 3 Dufitalein, soluble
in watci />«« — 150 gi subcutaneoubly 4
Ditjttnnin, not ncaily so powerful, allied to
saponm 3 Dinitm 6 Duntalic Acid 7.
Antirrhmw Acid Of these the fust three are
glucosides, and aie said to lepresent the action
ot digitalis on the caidiac mechanism The
fourth is a glucoside with an antagonistic effect.
Tho fifth is a glucoside and physiologically
inert •»
Pre2>aratinns — 1 Infusiim Digitalis Dose —
2-43 2 Tmctura Digitalis Dose — 5-15 m
The tinctuie contains a larger amount of digi-
toxm, and has therefore probably more marked
384
DIGITALIS
toxic and cumulative properties* Of the com-
mercial preparations used as digitalin, Nativelte's
consists principally of digitoxni, Jfoinollei of
digitahn, and the German forms of digitalem
Digitalis acts directly on the heart muscle,
and also on the terminations of the vagus,
causing a prolongation of diastole and a powei-
fnl increase in systolic contraction It acts
directly on the nuibcuUr walls of the artenes,
causing eonti action of the vessels, and also
stimulates the vaso-eonstrictor centres The
combined effect on heart and vessels results in
a marked rise of blood-pressme Digitalis also
acts on other non-8 tuped muscles, ey the in-
testine, the bladder, and the uteius, hut this is
of less impoitance therapeutically The diuretic
action of digitalis is probably entirely of vasculai
origin The relief of \ cnous congestion and the
gene i eil improvement in the circulation may
sufficiently account for it, but many authorities
believe that accompanying the general arterial
contraction thcie is a i el ax at ion of the icnal
vessels resulting in an increase of blood -flow
through the kidneys Against this lattci hypo-
thesis is the fact that it has not been shovni to
have a definite diuretic action in health The
chief use of digitalis is in disease of the hcuit
Much confusion has arisen as to the different
types of cardiac disoider that aie suitable for its
administration, particulaily as icgaids Aalyulai
disease. The matter is simplified if we remombci
that no valvular affection is in itself eithei an
indication or a contra-mdication , that it is not
required when the heait is acting well and com-
pensation good , but that, as a general inle, it
should bo administered, irrespective of winch
valve is diseased, when the pulse is weak and
irregulai, the arterial tension low, and evidences
of backward pressure and venous congestion are
present Thus its chief sphere of usefulness is
in mitral affections, but the presence of an aortic
lesion is not necessarily prohibitive, for, whereas
with a powerfully acting left ventricle and a
strong leaping pulse its administration is not
only mational, but absolutely dangerous, its
use in cases whore the left ventricle is failing
has frequently the most beneficial effect, particu-
larly if large doses are given and the patient
kept in the recumbent posture during treatment
In cases of combined aortic and mitral disease,
or in aortic disease with secondary mitral insuffi-
ciency, digitalis acts well in combating the effects
of backward pressure. Digestive disorders, if
present, should, when possible, receive attention
before commencing the digitalis, as they are
very often aggravated by the drug The initial
action being slow, three or four days may elapse
before effects on heart and kidneys are observable
It is therefore advisable to begin with large doses,
say 15-20 in thrice daily, and then, when a re-
sponse is obtained, to dimmish the dose on
account of the well-known cumulative effects
Thereafter it is only by carefully noting the
signs, symptoms, and progress of each individual
case that we ascertain accurately the daily
amount lequued In the course of a prolonged
idmimstration excessive rapidity, slowing, or
niegularity of the pulse, dyspeptic symptoms,
licadoche, dtz/.mess, and sudden diminution in
the amount of urine passed are all indications
lor a smaller dose 01 a temporary withdrawal
ot the drug At the commencement of treat-
ment, however, such symptoms as weak and
irregulai caidiac action and diminished secretion
of urine impiove veiy slowly or not at all , and
it is only after boldly pushing the dose for
soveial days that we aie justified in concluding
that the patient is not going to react to digitalis.
In fatty heart, m simple dilatation, and in some
cases of cardiac 11 regularity and weakness with-
out disco vci able cause, digitalis may be of great
service It is also useful in a laige number of
acute and chiomo diseases in which there is
cardiac debility In acute endocarditis it should
be avoided altogether, but sometimes when the
acute stage is ovei and the patient is convalescent
small doses give fa voidable results It must be
given with great caution when the arteries are
degenerated, on account of the nsk of cerebral
hnmiorihage In uncomplicated Bright's disease
it is very rarely indicated, certainly never as a
diuretic In rare cases, however, both in the
acute and chronic forms, weak and failing heart
action constitutes the most serious symptom,
and may of itself call foi the use of digitalis
In hwmoiihage digitalis does inoie haim than
good, the aiteiiole conti action being more than
co untci balanced by the increased pulse tension
and force of the heart's action
DiglOSSla. — A rare malformation, in
which there is duplicity of the tongue, usually
due to fissure of the oigan (Xchistoylosna)
DlhydriC AlCOhOlS.— The dihydric or
diatomic alcohols aie dihydroxyl-denvatives of
hydrocarbons, two hydrogen atoms being dis-
placed by two hydroxl groups , thus from
benzene (CflH(l) is got ie«orcm (C<(H4(OH)2)
Dilatation. — Enlargement or expansion,
or the part enlarged or expanded. Thus thcie
is dilatation of the heait, of the bronchial tubes
(bronchiectasis), of the stomach, of the veins
(varix), of the arteiics (aneurysm), of the cervix
uteri (in labour), and of the cerebral ventncles
(hydiocephalus)
Dilator. — An instrument used for the
purpose of opening up or expanding a natural
opening, passage, or canal, eg. Holt's urethra!
dilator, Hegar's or Barnes's cervical dilators, and
Bossi's metal dilator used in accouchement force ,
also a muscle which causes dilatation of an open-
ing, such as the dilator pupilleo and the dilatores
DILECANUS
385
DllecanilS. — United twins or double
monster, in which the head and chest are single
and the pelvis double (Gr Ac/cos, a dish or
pelvis) , tho term was introduced by Taruffi
(1889) , and the pelves may be situated side by
sido (Dilecanus dipleurus), or may be attached
to each other in the pubic regions (Dilecanus
tbipayus)
Dill Fruit. See ANBTHI FRUCTUB
Diluents. — Medicines or indifferent sub-
stances which increase the proportion of watei
in the blood and other Ixxlily fluids, which, as
it its said, " thin the blood " Water is the most
commonly employed, and its action is aided by
the addition to it of lemon peel or on acid
(which increases the flow of saliva) Diluents
render the urine less initating, diminish thirst,
and remove products of disordered metabolism
from tho body, they are therefore used in
cystitis, diabetes, fe~ver, gout, rheumatism
See PHARMACOLOGY , PRESCRIBING , etc
Dimethylamlne.— A hquid (NC2R7)
having an ammomacal smell , it has been found
in decomposing fish, and is a ptomaine or
animal alkaloid Dimethyl (C,H(l) is ethane 01
ethyl hydride , in dimethylumino two of the
hydrogen atoms of ammonia have been replaced
by ethane See SNAKE-BUBS AND POISONOUS
FISHES (Fmsonoui Fish, Putrefaction)
Dlmethylarslne. See TAPODYL
Dimethyl benzene. See XYLENE
Dimidiate. — Divided mtot\\o, double,
eg a placenta consisting of t\\o nearly equal
parts is a dimidiate or duplex placenta
Dimple, Postanal. — A
or umbilication found immediately behind the
anus, over the lower end of the sacium or
coccyx , foveola coccygea , it may be suiioiinded
by a ring of hails , it may bo associated with
spina bihda, and may be the seat of a fistula, or
sinus, or cyst, or dermoid See Ballantyno's
Antenatal Patholoyy, vol n p. 327
Dl n It robenzi ne. See TRADES, DANGER-
OUS (Aniline Poisoning)
Dlnomanla.— Choreomama or dancing
mania (from Gr Sivos, a whirl, and parto,
madness).
Dl nsdale -On -Tees. See BALNEOLOGY
(Great Jintain, Sulphur)
DlOCtOphyme Glga&m — Strongylut
gigas , a largo nematode occasionally found in
man. See PARASITES (Nematodest Strongylufa,
JSustrongylus giyas)
DlOdon. — Porcupine fish, regarded as
poisonous. See SNAKE-BITES AND POISONOUS
FISHES.
DlOdonceptialUS.— The deformity m
which there is a double row of teeth in the
same jaw
D (Oestrum.— The short resting stage be-
tween two cestrous cycles as seen in polycostrous
mammals, such as the sheep and tho mare
See ANCESTRUM. /•
Dion In. — Dionin is ethylmorphino hydro-
chloride (CiqHMN08 HC1.H20), and has the
medicinal properties of morphine, with, it is
«aid, less liability to produce the morphine
habit, it has been specially recommended (in
doses of J to J gram) in whooping-cough, in
asthma, in eye practice, and in internal painful
conditions (gastric cancer or ulcer, colic, etc.).
Dioptre.— The unit of optical power , the
optical strength or refractive power of a lens ot
one metre focal length (" A convex lens inter-
posed m tho path oi a parallel beam of light
brings the light to a focus at a constant distance
from itself, \vhich is called the focal length of
the lens") See REFRACTION (Lenses) The
dioptric mechanism by which an object is seen
as single by two eyes is described m the article
PHYSIOLOGY, THE SENSES (Vision, Monoculat)
DiOXybenzene.— Diphenol , ben/ene m
which 2 atoms of hydrogen have been replaced
by 2 molecules of hydroxyl, CbH4(OH)B , there
are three isomoric varieties — (1) orthodioxy-
bcnzene or pyrocatechm, (2) metadioxybenzene
oi resorcin, and (3) paradioxyben/enc or hydio-
qumone See PHYSIOLOGY, EXCRETION (Urine)
DlOXypurln.— Xanthm (CBH4N402).
DlphallUS.— The deformity (probably a
low degree of double monster) in which the
penis is double, there may be evidence of
duplication of the lowei end of the spinal
column m such cases as well as of the bladder
Diphtheria.
HibroRY AND GEOGRAPHICAL DISTRIBUTION 386
ETIOLOGY 386
CLINICAL HISTORY 389
Faucial Diphtheria 389
Nasal „ 389
Larynqeal „ 389
Wound „ etc 390
SYMPTOMS AND COMPLICATES 390
MORBID ANATOMY AND PATUOLOG\ 392
DIAGNOSIS 394
PROGNOSIS 395
TREATMENT 396
Antitoxin 396
Local . • 398
Intubation and Tracfaotomy 399
General, Dietetic, and Medicinal 399
Isolation and Disinfection 399
Prophylaxis 400
25
386
DIPHTHERIA
See also ALCOHOL (Indications in Diseases of
Childhood) , AMBLYOPIA (Tone, after Diphtheria) ,
ASPHYXIA (Causes), BRAIN, INFLAMMATIONS
(Acute Encephalitis, Etiology) , BRAIN, AFFEC-
TIONS OF BLOOD-VESSELS (Ceielral Thrombow,
Cawing Hemiplegia after Diphtheria), DIS-
INFECTION (fncubatton Periods and Quarantine),
GASTRO - INTESTINAL DISORDERS OF INFANCY
(Diseases of the (Esapha<]usy Diphtheria) ,
HjbMATEMEsis (Lemons), HEART, MYOCARDIUM
AND ENDOCARDIUM (Nimple Endocarditis) , IM-
MUNITY (Diphtheria), INFECTION (Rules for
Prevention of Infectious 2>tseaw&) , INTUBATION ,
JoiNrs, DISEASES OF (Pyogenic Diseases) ,
LARYNX, NEUROSES OF (Paralyns of Vocal
Cords), LEUCOCYTOSIS (Inflammatory and In-
fective Conditions), MEASLES (Diagnosis},
METEOROLOGY (Seasonal Prevalence of Diseases) ,
NERVES, NEURITIS (Causes of Mono-Neunti^) ,
NERVES, MULTIPLE PERIPHERAL NEURIIIS
(Diphtheritic) , OCULAR MUSCLES, AFFECTIONS OF
(Etiology) , OXYGEN (Inhalation and Hydrogen
ret oxide Application), PNEUMONIA (Pneumo-
COCCUb) , PUBRPERIUM, PATHOLOGY (SeptuCPIMO,
Diagnosis), PUERPEUIUM, PATHOLOGY (Nipple*,
Diphtheria), PURPURA (Symptomatic, Toxu) ,
STOMACH AND DUODENUM, DISEASES OF (Afem-
Itranous Gasttttit) . THERAPEUTICS, SERUM -
THERAPY (Antidiphtheritic Serum) , TRACHEA,
AFFECTIONS OF (Tracheotomy).
DIPHTHERIA is an inflammatory infectious
disease, usually of mucous membranes, of w hich
the essential cause ib a specific micio-orgamsm
The inflammatory piocoss is often attended by
the formation of false membtanes The absorp-
tion of the toxic products of the micio-oiganibm
produces secondary effects , of these a peculiar
form of paralysiw is the most characteristic
The name diphtheria we owe to Bretonueau
<1855) He had previously (1821) used the
term diphtheritis
HlHIOm AND GEOGRAPHICAL DISTRIBUTION —
The disease was first dcscubod by Arutcims of
Cappadocia in the second century AD, who
mentions that it was prevalent in Egypt and
Syria ^Ktius, in the fifth century, was
acquainted with it During several succeeding
centuries there occur at long intervals of time
only a few doubtful records of the disease, and
it is not till the sixteenth century that a more
definite account is forthcoming In 1517
Hecker described a fatal form of infectious
angina that appeared in Holland, and later in
Basle During the latter half of the century
the disease was prevalent in Southern Italy,
Spain, and Portugal , there were also outbreaks
in Paris and Dantzig Epidemics continued to
occur duungtfthe seventeenth century in Italy,
Spain, and Portugal, and m the following
century Noithern France, Holland, Switzerland,
Germany, Sweden, England, and North America
were invaded Towards the end of the eighteenth
century, however, diphthena seems to have
been somewhat diminishing in its prevalence in
the countries we have named , and though from
time to time outbreaks are reported in various
quarters during the first half of the nineteenth
century, it was not till its middle that the
disease began again to be serious over a wide
area Since then it has been and still is, more
or less, pie vale nt all over Europe and in North
America and Australia , to a less extent also in
certain districts of South America, South Africa,
India, and China.
ETIOLOGY — At the present day, therefore,
diphtheria is a very widely spread affection
The accumulation of properly compiled records
of the fatal cases m various countries during the
past twenty-five to iifty years has enabled m-
qmreis to elucidate several important facts with
respect to its etiology Amongst the most recei t
and valuable researches in this field are those of
Ncwsholme This author draws conclusions, of
which the following is a buel summary —
Diphthei la has a tendency to spread from one
place to .mother by the oidmary channels of
communication In certain ) eai s diphthei la may
be pandemic over whole countries ot a continent
The amount oi endemic diphthei la \aries greatly
for diffeicnt countries and titles, but "m no
town fiotn which lecoids have been obtained is
theie a complete absence of the disease in a
single year since the iccords commenced " In
places where the amount of endemic diphthena
is not gieat, epidemics tend to occur in cycles,
the intervals between the cycles being very
variable for different places The duiation of
an epidemic is also variable, but is usually
longer in large than m small cities 01 towns
Before the appearance of Newsholme's work
it had been shown that foi England and Wales
one of the most striking features with respect to
the prevalence of diphtheria was that, whereas
up to 1880 the disease was incident upon the
mral to a gieatei extent than upon the urban
population, since that date the reverse has been
the case, theic has been an increase both in
luial and urban diphtheria, but the urban inci-
dence has usen to a much highci dcgicc than
thermal London has especially suffered News-
holme's observations show that this increase m
ui ban diphtheria is not confined to England and
Wales, but has also occurred in countiies so
widely separated as the United States, Japan, and
South Austialia It is reasonable to suppose
that the wondeiful improvements effected during
recent yeais m oui means of transit have had no
small share m contributing to this increase
Like most infectious diseases, diphthena has
its special seasonable prevalence, which, when
estimated by the recorded deaths, is in this
country from September to the end of the year
In London a marked rise in the notifications is
observed in July The consideration of the
influence of soil and chr/iatic conditions upon the
DIPHTHERIA
387
prevalence of diphtheria has led to considerable
diversity of opinion While some writcis deny
that these conditions exert any material effect,
it is held by othei M that a soil which is continu-
ally inoibt and impicgnatcd with oigamc refuse
is favourable to both the existence and \ n ulence
of the diHcabc Ncwsholme, in the \\oik from
which we have alicady quoted, gives the results
oi his inqumos into the relation bet \\cen epi-
demic rhphtheiia, the mintalt, and the level of
the f/iouru?' water The gcncial conclusions to
which he comcb die abbieviated by himself as
follows —
"An epidemic of diphtheria never originates
\\hen there has been a series of yeais in which
each year's lanifdll is above the aveiage amount
An epidemic oi diphthena ne\ ei oiigmatcb or con-
tinues in a \vet year (i e a year in which the total
annual rainfall is materially above the avciage
amount), unless thib \vet yeai follows on two 01
more diy yeais immediately piecedmg it The
opidi'iintb ot diphthona, foi \\hich au'iuato data
aie available, ha\c all oiigniitcd in dry years
{ie yeais in \\hich the total annual lamfall is
mateiially below the aveiage amount) The
greatest ,iud most c\teusi\e epidemics of dipli-
theiia haxe ouiuied when theie have been foui
oi five consecutive dry years, the epidemic some-
times starting neai the beginning of this series,
-it other times not until neai its end Diy
yeais imply low gi ound-w atei , .indue find, theie-
ioie, in tlie yeais of epidemic diphthena that the
ground-w atei is exceptionally lo\\ The exact
\ariations in the giound-watci which most favoui
epidemic diphthena cannot w ith the data to hand
as ^et be stated , but it is piohable that when
this is cleared up, it \vill become clear why, in
exceptional yeais which have a deficient lamfall,
•epidemic diphthei la is either absent or but slight "
Ne\\sholme's conclusions aie at vaiiancc \\ith
the hithcito acce]>ted ideas coiiccniing the
association of dampness of boil and diphtheria ,
but they aie based on net mate iccoids Taking
up an idea put foi \\ard by M A Adams, ot
Maidstone, Newsholme suggests that the micro-
organibm ol diphtheria passes a saprophytic
existence in the soil, and that its growth is
favoured by a low level of the ground -watei,
such as would follow a deficient lamtall The
rise of the ground-water consequent upon id ins
duves the micio-orgamsm out of the boil , the
oiganism may then become paiasitic on man,
and an epidemic arise But this hypothesis,
w Inch may account foi the autumnal and \\ mtei
pie valence of diphthena in England, and lor
epidemics which aiise in \\et following dry years,
does not appear to explain the epidemics which
commenced in dry years, unless it be that the
rams that do fall during the dry years are
Bumcient for the purpose suggested, or that
variations in the atmospheric pressure, apart
from rainfall, have the same effect Moreover,
the diphtheria bacillus has not yet been found
in the eaith Diphtheria does not appear to
flourish in tropical to such an extent as m
temperate climates
Theie is evidence to show that m some
epidemics of diphthena the disease increases in
virulence as the epidemic pi ogresses At hist
sore throats of a mild character and questionable
nature occui , then in increasim/numbers cases
piesent themselves that are undoubted and
more se\ ere, even pro\ ing fatal , so that it
seems as if the organism of the disease gams
in vii ulence as it is transmitted from one person
to another
It is believed by some that tin oat lesions (e y
simple tonsillitis 01 the angina of siarlet fevci)
piedispose to diphtheria But the wntei ven-
tuies to doubt \\hethei a tin oat affection rendeis
the individual moie susceptible than does any
disease whuh loners the povsei of lesistmg the
attacks of pathogenic micio-oiganisms
AiMjciatton with othf) Diwuei — Diphthena is
frequently found awtriafnl witk othei ~ynwtic
<t i wises Itci/ywrus to have an especial liking
foi scarlet fev ei and measles, but it not infre-
quently attacks patients sufieiing fiom pertussis,
vancella, and tubei culosis , less commonly is it
found with enteric fever and small -pox It
complicates both the acute and convalescent
stages of these affections, and is more fatal
when thus combined than when occun ing alone
The occurrence of these coincident infections is
laigely determined by such factors as the age-
incidence and pievalence of the diseases con-
cerned Thus we hud fiom the published
statistics of the Metropolitan Asylums Board
that scai let fever attacks the patients convalesc-
ing from diphtheria quite as often as diphthena
does those iccovciing fiom scailet fever
Aye anil Sex and Ca*t-Jftntality — The London
notifications for 1892 to 1897 show that rather
moi e than one-thud of the cases aie under the
age of five jears, and lathci less than one-third
are between the ages five and ten With evciy
succeeding quinquennium the numbei becomes
\eiy much smallei Ago has also a maiked influ-
ence on the case-mortality This is highest in
infants undei one year It then giadually falls
up to the hfth yeai, and after that more lapidly ,
but it rises agam aftei forty Befoie the intro-
duction of the antitoxin ti eatmciit the case-mor-
tality of the patients undei hv e admitted to the
hospitals of the Metiopolitan Asylums Board
was 50 per < cut , fiom five to ten, 28 pei cent ,
from ten to fifteen, 10 per cent, fiom fifteen to
twenty, 4 pci cent , from twenty to foity, nearly
5 pci cent, and over forty, 17 pei cent
Diphthena attacks more females than males ,
this is usually attributed to the fact that the
nature of the duties and habits^>f the female
sex render its membeis more exposed to infection
than the male
Mode* of D is wm (nation — By far the most
common mode is by personal communication
388
DIPHTHERIA
between the affected aud the healthy, either
directly as in such an act as kissing, or perhaps
more often indirectly by means of utensils for
eating and drinking, handkerchiefs, toys, etc
The infection may bo harboured for a considei-
able time in such atticlos as wearing apparel
and toys It is not often conveyed by third
persons
There are uo\\ on iccord se\eral epidemics oi
diphtheria in which it has been clearly proved
that the infection was conveyed in mill In
some instances the souice of infection has not
been ttaced , in others the specific contamination
has been derned from a human source dining
the collection and distribution of the milk , in
a third group the infected milk has toon obtained
from cows that have IKJCU at the time the sub-
jects of a disease of the udder, a febrile affection
in which the local lesions consist of vesicles
which pass on to pustules and ulceis It was
suggested by Powei that the connection between
this disease and the specific infection ot the
milk was more than accidental Working at
the subject experimentally, Klein found that,
in five out of ten milch cows inoculated m the
shouldci with a v indent growth of diphtheiia
bacilli, thorp was pioduced after a few days an
eruption on the teats and udders similai to that
occuriing na tin ally The disease could be trans-
ferred to calves by inoculation In two out of
the five cases diphtheiia ba<ilh were obtained
from the milk yielded by the unmial, and in
two the bacilli were shown to bo picsont in the
^siclcs and pustules upon the uddet The
experiments of Klein, so fai as they go, corro-
borate Power's hypothesis It is tiuo that the
disease set up by Klein m the cow differs con-
siderably from that met with in the human
being, notably in the production of Aosicles and
pustules containing the specific organism in a
legion i emote from the seat of inoculation
With respect to the two similar experiments on
cows by Abbott (of Philadelphia) with negative
results, it may bo observed, firstly, that some
of Klein's own experiments were also negative,
and that the negative can hardly bo allowed to
weigh against the positive results, secondly,
that Abbott did not observe the same conditions
as those under which Klein worked Tho specific
bacillus has been found in milk presumed to be
the cause of an outbreak of diphtheria (Bowhill
and Eyre), but it has not }et been demonstrated
m the milk and in tho lesions on the udder ot
a cow to which a definite epidemic has been
traced
Besides its probable occurrence in cows, diph-
theria certainly attacks cats, and instances
have been recorded both where it has been
communicated" from the animal to man and
from man to the animal
There is no instance of diphtheria having
been conveyed by the water-supply, nor do
faulty sanitary arrangements in connection with
the lemoval of sow ago or refuse lead to out-
breaks. There has been marked improvement
made in the sanitary condition of this countiy
during the past thirty years or so, which has
icsulted in a notable lessening in the prevalence
of enteric fo\er, a disease which ceitainly goes
with bad sanitation of the kind to which wo
have alluded , yet diphtheria has become more
life dining that period But there is reason to
bche\e that insamtaiy conditions may aggravate
01 possibly picdisposc to diphtheria, and in this
way, thcieforc, theie may be said to be a connec-
tion between tho disease and its suiiouudmgs
School Influence — When wo remember th.it
diphtheria is especially a disease of children, wo
might iiiguc aptunt that the daily aggiogation
ot numbeis of such in<h\ uluals would tend to
widen its pie\alence And as a matter of fact
it has boon shown by moio than one obsoivei
(especially Thome Then no and Power) that a
local prevalence of tho disoaso has boon kept
up by such uggicgation Not only is it that
childicn catch the disease by being bi ought
into contact with infected children at school,
but they go home and infect othcis who are not
attending school In some instances the closing
of the school has markedly diminished the
l>ie>alence of diphtheria, and tho icopemng has
increased it In ccitain epidemics occurring in
not very populous imal districts the school
influence has not been ditluult to tiacc, and
cannot be gainsaid But the question aiisos
whethoi 01 not this influence is in operation
over largei areas and foi longoi pounds
It is not claimed by those who aic most
ronvctsunt with the problem that tho maiked
mcicaso of diphtheiia in tins countiy during
iccent yoais is entirely duo to school influence ,
but it is suggested that a considerable portion
of it is Tho two facts that aio brought fonvaid
m favoui of this \iew aie as follows — Tho
Education Act was patibetl in 1870, and since
that date theie has been fiom time to time
fuithcr legislation, which, while it has afforded
gieatci facilities to those who aie willing to-
send then childien to the Boaid Schools, has
brought more compulsion to bear upon those who*
are not The age of compulsoiy attendance is
from thiee to fifteen years Making allowance
for changes due to other causes that can be
fairly well ascertained, there has been since
1870 in London and m the provinces (including
Wales) a greater increase m the mortality (per
million living) at the age-period thico to fifteen
years than was to be expected, comparison being
made with the age-periods under three and over
fifteen, and with the years immediately preceding
1870. Tho other fact is that since the com-
pulsory notification of diseases was introduced
into London there has been a marked fall in the
already rising notifications at the age-penod
three to fifteen soon after the commencement of
the summer holiday (four weeks) of the School
DIPHTHERIA
389
Board, the fall continuing till shoitly after the
reopening of the schools at the end of the
holidays, when the notifications rise again
But the question is not absolutely settled
According to Ncwsholmc, in certain of the laigo
continental cities where compulsory school
attendance has been in force for many years, it
seems to have had no great influence one way
or the other upon the prevalence of diphtheria
Newsholme, howevei, is dealing with the
mortality of diphthcua for all .iges What is
required is a comparison of the mortality foi
the school agos \v ith that for other ages Accord-
ing to Muiphy, the figures for Berlin, as far as
they go, tell the same story as those for London
CLINICAL IIisTom — The tncuhitwn period is
from twelve horns to four days
Though any of the mucous membranes m iv
be the scat of tho disease, yet in the vast
rnajonty of cases the fauces alone are affected
Nc\t to the faucial tho noHal and laniygoal fonns
«iro the most common Tho conjunctiva, genit.il
organs, and cut meous \vounds are larely affected ,
still itiDi c lately the o?sophagus, ear, stomach,
uiethia, and bladdei
Faunal (ttjtht/ietui is veiy insidious in its
onset Such striking symptoms as frequent
vomiting 01 a ngoi oie lare The patient,
usually a child, is observed to look ill and
refuses his food The cer\ it al glands may be en-
laigod, and the paicnts peihaps think the child
has mumps If on thi* sign ot illness the
tempciatuie be taken, it will be found to be
raised (101° to 105° F) The pulse-rate is
slightly accelciatcd On inspection of the
f.iucoh the tonsils aic seen to bo slightly swollen
<md covered with a glassy film In adults, and
sometimes m children, soic tin oat is the fiist
symptom The subsequent com so of the attiick
vanes In a fatal case, untreated 01 tieatcd
too late with antitoxin, it is as follows -The
gla/y film becomes a definite yellowish exuda-
tion of a distinctly mombianous chai actor It
spioads fiom the tonsils ovei the soft palato,
uvula, and phaiynx (\eiy laiely to the month
and tongue), often forming a continuous sheet
The mucous membiane beneath is inflamed and
swollen, though only occasionally to an extreme
degree, and from it a slight oo/ing of blood
takes place Aftoi five or six days the exuda-
tion begins to decompose and sepaiate It turns
a, greyish black colour, and fiom it a pocului
and very offensive odour is given off Aftoi
sepal ation thcic is often icpcated le-formation
of mcmbtane In some coses the exudation may
have quite disappcaied before the fatal issue,
which usually takes place in seven to fourteen
days from the onset Meanvv hilc, v\ ith the exten-
sion of the local affection, the lymphatic glands
below and behind the jaw become moderately en-
larged and painful Occasionally also the skin
and subcutaneous tissue of the neck are swollen
The nasal passages are frequently invaded, and a
blood-stained watery discharge constantly ti ickles
from the nostrils, and from time to time rnem-
bianous casts of the nasal fossw are expelled
The temperature falls quickly after the initial
rise Its subsequent course is very irregulai
Briefly it may be stated that a fiesh extension
oi faucial exudation, 01 the occurrence of
adenitis, celluhtis, or broncho-pneumonia, leads
to a rise of temperature, but that during the
last three or four days, after the patient has
fallen into the final state of prostiation, it is
subnormal The pulse during the fust few
days is moderately frequent (100 to 130) and
compressible Then with the mci easing heart-
failure it falls m late, and the tension becomes
lower In most cases theie is ulbummuna
The constitutional symptoms arc those due to
progressive caidiac failure, increasing pallor and
prostration, diminished flow of mine, and frequent
vomiting Towards the end the patient is diow sy,
but i estless Tho mind is quite cleai and delirium
i is exceptional Death is due to syncope, and is
often attended by a slight convulsion
In non fatal cases the symptoms differ only
in dcgiec fiom those just described As a rule
the seventy of the constitutional symptoms
depends upon the extent of the local lesion,
which vanes greatly In the very mildest
forms theie will be two or three small patches
of exudation limited to one 01 both tonsils In
cases not so slight there aio numerous patches
on the tonsils, uvula, and palate The exuda-
tion is not necessarily membianouH, but may be
cheesy, pultaceous, 01 gelatinous It may com-
mence at one spot 01 simultaneously at many.
But the favounte place of origin is one of the
tonsils Occasionally it begins m the tonsillar
crypts In mild cases it icmams limited, and
lasts but a short time In such cases there
may be no constitutional symptoms
Nawl dtphthina i-. most commonly found ac-
com pain mg the faucial and laryngcal varieties
lint the disease may remain limited to the nasal
passages There is a disehaige, at fiist watciy,
af tei w ardh mueo-pui ulent, and occ asionally blood-
stained , often it is offensive and excoriates the
nostuls and lip The nose is more or less
blocked, and casts of the nasal passages may be
shed The constitutional symptoms aio raiely
seveio The discharge is often chrome
Laii/nyeal diphthtna is in the laige majonty
of cases secondai y to the faucial form It
occuis m from 11 to 15 pel cent of all cases of
clinical diphtheria, and anses within a v\eek
from the onset of the primary aflection It IK
quite the exception for diphthcna to start in
the larynx But inasmuch as the larynx may,
and often does, become involved in very slight
cases of the faucial disease, the svmptoms due to
its invasion may be the fust signs of the illness of
the patient The symptoms ate those of laryn-
geal obstruction , aphonia, stndor, a frequent
harsh cough, and recession of the chest-walls.
390
DIPHTHERIA
Any one of these symptoms may occur earlier, or
be more prominent than the others. At intervals
of a few hours there are in some cases attacks
of urgent dyspnoea, in which the patient be-
comeb much distressed and cyanosed These
attacks, which arise and pass off suddenly, aio
usually due to spasm of the laryngeal sphmctei
They may, however, he due to temporary
blocking of the larynx by a piece of loose
membrane If the diphtherml process spreads*
to the tiaehea and bronchial tubes there is
advancing and permanent dyspnoea and lividity,
and the patient dien ot suffocation On the
other hand, it is not at all infrequent, even
amongst cases not treated \\ith antitoxin, toi
the pi ogress of the disease to be ai rested at the
larynx, and the patient to recox er without any
urgent symptoms of larjngeal obstruction In
a few cases casts of the larynx, trachea, and
bronchi may be coughed up Lastly, it must
be remembered that the larxnx and icspnatory
tract below may be invaded without theie being
any symptoms to point to such an exent Thw
masked ioim of the disease is especially met
with in xery sex ere cases of faucial diphthcna,
the laiyngeal being obscuied by the extreme
severity of the other symptoms But it may
also be ol>servcd in less scveie cases unionist
adult patients In them the xvidth oi the
respnatoiy tract allows of the foimation of
membiano without mteiterence x\ith i espiration,
and it M not until the bronchioles become
blocked that dyspnoea aiises In these eases,
howcxei, there is usually aphonia, which is
therefoie an extremely giave symptom in diph-
thcua of adults
In rare cases there is expectoiation of easts
of the tiachea and bionchi, with absence oi any
such signs as chaiuctcrise obhtimtion oi the
larynx or the respiratoiy tract below it
In diphtheria of the rotywuttwi, membiane
forms upon the palpebral, larely upon the
oculai conjunctiva The eyelids aie swollen
Thecoinea may become inflamed and ukeiated,
perforation may lesult, leading to pan-ophthal-
nntis (vide "Coujuiu ti\ a") In mil ml dtyhllin ici
the labia muiora and the innci surfaces of the
labia majoia are co\eied with ashy giey mem-
biaiie, which may spread into the xagma
Theie is intense inflammation of the external
gemtalia and swelling of the neighbouring
lymphatic glands The constitutional symptoms
are severe, and are similar to those piesent m
the faucial foiin
Diphtheria of othei mucous membranes is i are
Wound diphtheria occuis in two forms In
one the membianous exudation appears upon a
previously existing wound, m the other the
wound is cuufced by accidental inoculation with
the diphthena bacillus A small chronic abscess
is the result
In severe cases of diphtheria, especially of the
faucial variety, the loeal exudation ma} persist
for three or four weeks. In rare cases of the
faucial, nasal, and laryngeal forms the local
affection may be of much longer duration, two
to six months Such cases are termed prolonyul
diphthfiict They commence m the same
manner as do the oidmary cases The larynx
may become involved aftei the faucial affection
has lasted some weeks. Except in the nasal
form a fatal termination is common
ASSOCIATED SYJIPHWH — A few woids aie
required concerning certain symptoms and con-
ditions moie 01 less common in the severer
forms of diphthena Alfatmtnwta is found in
fiom 50 to 75 pei cent of the cases It may
appear at any time dining the hist tlnee weeks,
sometimes latei Most commonly it is observed
about the fnuith daj Its duration and amount
aie ver> vanable Its piesence is of unpoitance
as ronghlv indicating the extent to x\hich the
absoiption of the diphthenal toxins has been
(anied The more peisistent albnminuiia, and
the gicatci the quantify of albumin, the more
severe is the case, and the more likely is
fiai.il} sis or caidmi irregnlanty to follow
Kxcopt in one other paiticulai, the condition ot
the mine does not deualc from the noiinal
We letei to the diminution ot the dail} quantity.
In most seveie cases this occms to a certain
extent, but theie may be complete &?////» is urm
of untie Usually this condition (omes on
about the sixth oi seventh day With it there
aie frequent xomitmg, algiditx, and caidiac
tailuie Death occurs alter two to foui dajs of
total suppression Occasionally fatal suppres-
sion arises m patients w ho appeal to be i eco\ ei ing
I loin the attack of diphthena
IfitmrntfuH/ic di/t/ithn HI — In some seveie
eases after a few da\s' illness cutaneous anil
subeutaneoiiH h.emoi i liases appeal, together
with a constant oo/ing ot blood iiom the nose,
phaiynx, and gums, h.emalemehis and mehvna.
These cases ai e almost im ai lably fatal ILemor-
ihages aie found post-moitem in the retro-
pharyngcal and peritoneal tissues, beneath the
pi om a> and mucous membiane of the stomach,
and into the lungs, caidiac and voluntary
muscles In rare cases a purpuiic condition
anses dining the period ot con \alesccncc
During the acute stage of diphtheiia theie is
a matked increase in the numbo of leucocytes
in the blood This condition disappears (lining
eonvalescenee
COMPLICATIONS — With the exception of
paralysis and ccitain caidiac complications,
these nsnjilly anse dunng the peiiod of the
loeal aflection The most eommon aie otitis
media (in about 7 per cent of all the cases),
Itilulw pnevmfMta (3 per cent, especially in
laryngeal diphthena), and ceivical adenitis,
n'llulitis, and abwe^ Lular pneumonia, nejih-
> ttt8,convul8ion8, endocarditis, venous and cardiac
thrombosis, embohsm, pytmnia, and ei ythematoui
aie raiely met with Though the local
391
exudation usually clears off without leaving any
loss of tissue, yet occasionally sloughing and
ulceration result, and may lead to septtcamm
The most important and striking complication,
or more frequently sequel, of diphtheria is
patalf/nt The proportion of cases in which it
occurs vanes At the Eastern Hospital during
1892 and 1893, before the introduction of the
antitoxin tieatment, it developed in ibout 18
per cent of those patients w ho survived the acute
stage of the disease, and in 12 pei cent of all
cases It occin ri moio frequently, iclatively as
well as absolutely, in children than in adults ,
it is more often observed to lollow a severe than
a mild attack ot diphtheiu , and though it may
succeed any form of the disease, yet it is met
with more frequently after the faucial variety
Paialysis usually sets in during the second,
third, or fourth week from the commencement
of the attack of diphtheria, but it may .11 IBP as
caily as the fifth day, or .is late as the twelfth
week The fiist symptom is common 1\ a nasal
\oicc, 01 a login gitation of liquid tlnough the
nose duimg the act of dunking The soit
palate will be lound to be motionless, and its
sensation and reflex imp. mod 01 lost Often
the paralysis remains limited to the palate, but
it may progress to a gieatei 01 less extent,
various muscles 01 gioups of muscles becoming
affected in a sequence moie 01 less regular
The ciliary muscles aiu involved CMily, and the
patient iss unable to detmc near objec ts cleai ly
Then the gait becomes unsteady and the lowci
extiemitics nicak Strabismus and othei signs
of oculai paialysis aroohsencd , and, lastly, the
muscles of the neck, tiunk, uppei extremities,
and lespnution being ailectccl, the paialysis
becomes generalised, and the patient is help-
less
The frequency with which the ditteient
groups of muscles are imohed may be gathcicd
horn the following tigures —Of 125 consecutive
cases of paialysis analysed by the wnter (see
Jhani, I89r>), in 102 the palate was affected, in
5G the ciliaiy muscles , in 52 the lowei extiemi-
tics, in 2(J the external ocular muscles , in 21
the uppei extremities, in 14 the lai\nx , and
in 10 the diaphragm In 19 cases dithculty
in swallowing waspicsent, but this number is
probably too small, because many patients aie
placed oil nasal feeding .it an early stage of the
disease, so that paialysis of the pharyugeal
muscles occurring subsequently escapes notice
It is rare for the sphincters ot the bladder 01
rectum to be imohed Occasionally there is
weakness ot the oral muscles, but marked facial
paralysis is exceptional Paralysis of the tongue
is very rare
Frequently the paralysis remains limited ,
this was the case in 6G of the 125 cases (52 8
per cent) In 28 it was confined to the palate ,
m 17 to the ciliary muscles , m 11 to the palate
and ciliaiy muscles , in 6 to the palate and legs ,
in 3 to the palate and ocular muscles , and m 1
to the respiratory muscles
Of the extrinsic muscles of tho eye the
external recti (usually the left) aie most often
affected Complete ophtlialmoplegia is rare
The reactions of tho pupils become sluggish,
but tire seldom abolished In l.trvngcal para-
lysis most commonly all the muscles are in-
volved, so that there is aphonia and a toneless,
ineffectual cough Abductor paralysis is ex-
ceptional
Tho loss of mu^culai function is raiely com-
plete, even in the most seveie and generalised
cases There is paiesis lather than paralysis
Nensation may also be impaired Adults will
complain of tingling or numbness of +,he tongue,
fingers, and toes Careful testing will then
usually elicit impairment of common sensation
The special senses are veiy rnioly iffectel
Optic npuijti<o and atrophy do not occur The
knee-jerks are as a i ule abolished Indeed it is
not inn ommcm to find them absent in cases of
diphtheria befoie paralysis has set in, and even
in cases where there is never paialysis at any
time It ma\ be months befoio they aio
icstorcd Occasionally a stage of exaggeration
precedes their disappeaiancc The supei final
leflexes icmain in all but the most sevctc cases
In the geneiahscd iorm theie is much wasting
Tho elc< tucal reactions aie diminished , but the
HMctum of degeneration is uncommon
Distill bailee of the en dilation was met with
in 29 of the 123 ca^es The heart's action is
increased in frequency and is irregular Occa-
sionally theio are more severe symptoms such
as are mentioned below undei caidiac complica-
tions
In 4 cases, in all of which theie was paresis
of tho respiratory muscles, there was icspiratory
niegularity of the nature of " (/heyne-Stokes
bieatlung" In taie instances sudden attacks
oi dyspnuM, occui (lespuatory crises)
Thirteen of the 125 cases (104 pel cent)
died of paralysis or its effects, 6 of these were
iatal from caidiac failure, 4 from lespiratory
paialvsis , 2 tiom peisistent vomiting and
caidiac f dilute , and 1 horn comulsions
V hen theie is lespuatory paialysis there is
gieat iibk of ^uffocation from accumulation ot
mucus in the lungs In paralysis of the phaiynx
and larynx the patient may be choked by
untiaucc of tood into the laiynx if caie in
lecding bo not cxciciscd
In seveie generalised cases the patient
becomes veiy apithetic, and appeals not to
notice what is taking place aioiind him. The
sah\a ac cumulates and dribbles from the mouth
or, unless the head be lowered, trickles into the
larynx Muscular to itc lungs, especially of the
face, aio sometimes observed
The duiaticm of an attack of paralysis varies
from a few days to ten or twelve weeks, chiefly
according to the extent of the paralysis. When
392
DIPHTHERIA
once the patient begins to improve, recovery,
which IB always complete, progresses quickly.
There does not appear to be any i elation
between the seventy of the paralysis and the
interval of tune that elapses between the attack
of diphtheria and the onset of paralysis But
in generalised cases the more rapidly the
paralysis bpreads the more likely is the issue to
be fatal.
The introduction of the antitoxin treatment
has had a maiked effect upon the incidence of
paralysis. On the w hole this has been increased,
probably because a larger number of severe
cases are tided over the acute stage of the
attack of diphtheria Indeed, this increased
incidence has taken place entirely in those cases
brought under the treatment at a late stage
Amongst cases treated early the incidence has
diminished very considerably According to
Woollacott (Lancet, 26th August 1899) large
doses of antitoxin (4000 units and upwaids) are
probably more effective than small in preventing
paralysis and lowering ite mortality
The much and rightly dreaded caidiac com-
plications are usually met with fiom the end of
the first to the fifth or sixth week, but ia
paralytic cases they may arise- later The most
common is dilatation, which leads to irregularity
and attacks of syncope When acute, the
dilatation is accompanied by vomiting and
severe epigastric pain Irregular rhythm,
tachy- and bradycardia may also occur with,
but also independently of, dilatation All these
conditions are very grave , apait from a fatal
issue they are apt to peisist for a considerable
time in .spite of careful treatment.
An>rvua is a fioquent sequel of nn attack of
diphthena.
A maikcd relapse occurs in about 1 pel cent
of the cases As a rule it is not so seveic as the
prnnaiy attack Secondary attacks of soie
throat, not clinically diphtheria, are still more
common Probably they are of the nature of
relapses. Second attacks, occurring after several
months or years, are not uncommon It is
probable that an attack of diphtheria confers
little, if any, lasting protection against anotlu-i
attack
MORBID ANATOMY AND PATHOLOGY — The
essential cause of diphtheria is a bacillus, often
called, after its discovcrcis, the Klebs-Loeffloi
bacillus This oigamsm, oithei itself exciting
.in inflammation of a mucous surface or cutaneous
wound, 01, less frequently, becoming active in an
inflammation previously set up by some othei
agent, gives rise to an exudation which in the
majority of cases is distinctly membranous
Membrane — To some mucous surfaces, especially
that of the fauqp s, this membrane is very closely
adherent Consequently, it w with difficulty
separated therefrom, and its removal is often
attended with bleeding. But to the mucous
surface of the nasal fossae, larynx, trachea, and
bronchi, it is as a inle much less closely attached.
When the membrane has separated naturally,
breaches of the underlying structure are left
which are usually slight, though occasionally
they arc both deep and extensive Microscopi-
cally the false membrane consists of a hyaline
fibnnous matnx, having eithei a granular or
fibrillatcd appearance, in which a leucocyte can
here and there be seen It may also be dis-
tinctly laminated When it is closely adherent
to the mucous mcmbianc, the latter is more or
less deeply infiltrated with fibrin and leucocytes,
and its epithelium is necrosed and uicorpoiated
u ith the talso membrane Beneath the infiltrated
layer the tissues exhibit the appearances of in-
flammation Micro - organism* jnewnt — The
diphtheria bacilli are found upon the surface of
the false membrane, usually in a continuous
layer Occasionally they ponctiatu as deeply as
the mucouH membrane Other micio-organisms
aio also present, especially stiepto- and staphylo-
cocci, and they may bo found invading the
adjoining mucous membiane Exceptionally
the Klebs - Loefflci bacilli are found in the
lymphatic glands, spleen, lungs, and othei
organs, and also m the blood Piobably this
general invasion of the body tikes place shortly
befoic death, \vhen all lesistancc to the entiauco
oi the bacilli has been oveuome
(iiow pathological change^ — In most cases an
autopsy ie\cals to the unaided eye little beyond
the local lesions The skin, hcait-musclo, and
kidneys may be unusually pale The ic-rvical
and occasionally other lymphatic glands are
inflamed Microscopically the heait-niuscle is
found to have undergone a fatty dcgeneiation
moie or less extensive Sometimes also there
is a similai change m the iciial epithelium , but
the lesions of nephritis arc rare In cases fatal
dining paralysis there is degeneration of the
affected nerves These changes are found
mostly in the peripheral noi\es There is a
breaking up and disappcaiancc of the \vhito
substance of Schwann, followed by a degeueia-
tion of the axis cylinder
The /iacillus —The bacillus of diphtheiia is a
rod-shaped, non-motile, polymorphous 01 ganism
It varies m length from about 1 5 to 6 p
Often its protoplasm docs not stain unitoimly,
and hence the bacilli have a beaded appearance.
The longer forms are frequently clubbed at one
end, and slightly cuived The shorter forms
may bo \\edge-shnped Usually the bacilli arc
irregularly grouped together , but they may,
especially the shortei forms, be arranged in
pairs, and groups may be seen of se\eral pans
disposed parallel to one another They do not
form spoies. They can be artificially cultivated
m various media Their size and appearance
depend considerably upon the medium and
method of cultivation There is another bacillus
met with in cases of diphtheria, as well as in other
throat affections It is a short, wedge-shaped,
DIPHTHERIA
393
non-motile bacillus The bacilli aie arranged
in groups of parallel pairs, the pairs having
their bases m appoutiuii When stained it does
not present a beaded appearance This nuciobe
does not vary \\ith its cultuio medium to biich
a degree as the diphthciia bacillus It IN not
pathogenic to animals When grown m neutral
broth it renders the medium alkaline from the
first, \vhereas the diphtheria bacillus renders it
firstly acid and then alkaline Tins bacillus has
been called Hoffmann's, the bhoit diphthciia,
and the pseudo-diphthciia bacillus
Btictti iolo</tcal Inwttu/tition — A bacterio-
logical examination for diagnostic pin poses is
made as follows — With a sterilised cotton- vool
swab, a loop of platinum x\nc, 01, bettei still,
the flattened end of a platinum rod, a small
poition is removed fiom the edge oi the exuda-
tion , or if none be piesent a sci aping is made of
the mucous bin face The s\vab m KM! is then
smeared slightly ovci the suiface of steiihsed
blood-seium in a test-tube The tube is placed
in an incubator at 37" ( ! Colonies of diphtheria
or ot Hoffmann's bacilli can be seen in twelve to
twenty-four hours as an opaque white streak 01
disci etc points Glow ths due to othci organisms
appear later, and aie usually eithei tiansparciit
01 not white Occasionally, ho\\e\ei, colonies
icsemblmg those of the diphtheiia bacillus aie
piod need by other organisms, so th.it no ic-
hancc as to the natuie of the giowth tan be
placed upon a naked-e^ e examination As soon
as it IN convenient aftei the growth has become
\isible it should be microscopically examined
The bacilli may be stained by Gram's method,
or with a solution of catholic methylene blue, 01
othei aniline djes
Inoculation Effects — The ctmm citterns of
diphthena is the Klebs-Loefller IMC illns It can
be cultivated fiom the exudation in the vast
majoiity of cases that aie clinically diphtheria
When inoculated upon the mucous membiaues
of ceitam .umnals (e <j guinea-pigs) it sets up ,m
inflammation \v Inch may be membranous When
inoculated subcutaneously a local exudation
results, mound x\huh theie is extensive crdcma
Necrosis of the tissues follows, and the animal
wastes and dies in a few days Aftei death
pleurisy, bioncho-pneumoma, hfemoiihage into
the adicnal bodies, anddcgcneiation of noi ves and
muscles ai o found In cases vv hei e death is delayed
beyond fom or five days the animal has p-ualysis
of the extremities If the diphthena bacillus is
grown in broth undei certain conditions, it pio-
duces m the bioth bodies which by infiltration
can be freed from bacilli These bodies, accoid-
mg to Sidney Martin, consist chiefly of albu-
moses, with an oigamc acid Torm — Collec-
tively these bodies may be included under the
term diphtheria - toxin When the toxin is
injected into a rabbit or gumca-pig it gives use
to, amongst other symptoms, paralysis of the
extremities and trunk Microscopically theie
arc dcgenciativc changes m the neives and
muscles similar to those found m human beings
who have died of diphthenal paralysis From
the blood and tissues (especially the spleen) of
patients who have died of diphtheiia similar toxic
Ixxiies can be exti acted It has already been
stated th.it the diphtheria bacillus is as a rule
confined to the local exudation iience the
inference from the experimental evidence is that
the b.u illus manufactures toxic products loeall) ,
and these being absorbed into the system give
use to the degenerative changes so commonly
met with Martin, however, believes that the
bacilli pioduce locally a feiment, which, being
absorbed, aits on the prott'ids of the tissues and
gives rise to the poisonous albnmoses
I'tnldimi in lh<> Patholiufy of 1tie Disease —
Theie aie thiee points concerning the pathology
of diphtheria which aie \K«thyot notice (i )
With lespect to the accfjttante of the Kltbs-
LofJIltt buctlltii «i thf ewnfiaf mu<se of diphtheria,
it pi o ves a stumbling-block to some persons
that it is occasionally found not only in morbid
conditions of the fauces and mouth other than
diphtheiia, but also in healthy tin oats Theie-
fore, they say, this bacillus cannot be the cause
ot diphtheiia To agiee with these object oih,
howe\cr, one would have* to ignore absolutely
the whole ot the experimental evidence in its
favour, which is not only exceedingly strong in
itself, but has directly led up to the most
successful method of ti eating the disease hitherto
discovered In older to its development the
bacillus doubtless lequnes the influence of one
01 moic fax om able conditions, without \vlnch it
possibly xv ill not manifest any pathogenic action
x\ hatsoev er Hut, on the othei hand, let all these
conditions be present w ithout the bacillus, and
thcic Mill be no diphtheria
(n ) An othei question of inteic-st lelates to
\\wwiiifttton in miiilrme ot the LmtUns The
study of epidemic diphthei 1.1 points to the con-
dusion th.it the vaiiation may be extreme, and
that in the couise of an epidemic it may be
exalted iiom a low to a high degree of malig-
nancy find vne ?i»sci Uoux and Yersm suc-
ceeded in attenuating the xnulcnce of the
bacillus b) cultixatmg it m bioth for a month
at a tempeiatuie of 39 5C C They x\eie unable
to rcstoie the xnulence when it had been com-
pletely desti ox ed , but x\ hen the viiuleme v\as
only partially lost it could be legamed by in-
jecting into animals the sticptococcus eiysipelatis
along w ith the attenuated bacilli It has been
suggested by moie than one bacteriologist that
Hoffmann's bacillus is an attenuated form of the
Klebs - LoefHer oigamsm But no convincing
evidence of this suggestion has hitheito been
brought foiward In order i% prove that the
former has leally been com ei ted into the latter
oigamsm it is required that from the broth in
winch subcultures of the changed bacillus have
been giown the characteristic toxin of diphthena
394
DIPHTHERIA
shall be extracted, a toxin not only capable of
bringing about tho nerve and muscle degenera-
tion already described, but also neutrahsable by
the diphtheria antitoxin And this has not yet
been accomplished
(in ) Lastly, it must be mentioned that some
authonties, especially the French, believe thtit
tho strepto- and staphylococci and othei
organisms HO commonly found in the local
exudation in a case of diphthciia have no small
share m the pathology of the disease They
state not only that to these oigamsms arc due
such complications as adenitis, cclluhtis, sup-
puration, and so forth, but also that the \iiu-
lence of the diphtheria bacilli is heightened by
their presence Hence they speak of "puio"
and " associated " diphtheria , moaning by
"pure" cases those in which a puic cultivation
of the specific organism is obtained from the
exudation, and by " associated " c ases those in
which the diphthciia batilh ate associated in the
cultivation with a laige numbei of other bacteria
While the muter shates this MOW in HO fai ab to
agree that in some cases certain of the com-
plications mentioned can be attributed to the
associated organisms, he cannot subscribe to th<
belief that they aie .ill so caused , noi is he of
the opinion that the " associated " is necessanlj
graver than the "puie" lorm In his ex-
perience the clinical tesults of tho antitoxin
treatment aie quite against this vic\v. Hv
merely examining a giowth on seium 01 a slide
under the micioscope no knowledge is to be
gained «is to the seventy ot any given case
DIAGNOSIS — Since in faucial diphtheiia m its
earliest stage, anil in many cases at a latei
period also, the exudation m slight and not
mcmbianous, and constitutional symptoms may
be absent, it is easy tn undet stand how difficult
it is to distinguish the disease fioiu other founs
of soie tin oat, moie especially Dimple and
Jolliculai toniitlttts Every case of this kind
should indeed be legaided with suspicion, and
forthwith isolated and injected with antitoxin
A bacteriological exumin,^i™i. hl.ould at the
same time be made, ar \ m the absfwe ol any
definite < Imical symptoms the diagnosis should
rest upon the result Of this examination It
should, how/ voi, be borne in mind1 that owe
negative result is not sufficient upon which to
pronounce an opinion th.it tho case is not one
ot diphtheua Of the two iorms of t&usilhtis
above mentioned diphtheiia assumes the simple
tnore often than the folhcular JJcsidcri these
the affections most commonly taken for diph-
theria ,«e wnplr ulcnation. of the ty«s//,
catan/ial inflammation of the fauces, and Jenifer
fever with anytna The very existence
ulccration (union* very superficial) is
diphtheria In eatarrhal sore throat the
and the w hole of the mm ous membrane of
fauces are slightly swollen, and at first
Later there is an excess of mucous secretion!
Often tho inflammation extends to the nasal
passages (producing a discharge at hrst thin
and watery, aftei wards muco-purulent), larynx,
and tiachea (giving use to hoaiso cough and
pain in the chest, larely to urgent dyspnoea)
There may be slight pyrexia, and the patient
feels chilly and out ot soits Tho condition IH
not infrequently met with in influenza
Srtulet Jevet is often diagnosed as diphtheria,
much less often is the lattci affection mistaken
for the ioimei The eiror anses, firstly,
thiough the obser\ci being unavoidfibly com-
pelled to make a diagnosis before the appear-
ance of the lash , secondly, through the omission
to look for a lash, and, thirdlv, thiough the
absence of a rash The onset of starlet fever is
usually accompanied by \omiting, which is not
the mle in diphtheiia A high temperature,
dclmum, and maiked swelling, with vivid icd-
ness oi the iauces generally, are in favour ot
scai let fever Hut it is often impossible to dis-
tinguish a mild case of scarlet tevei beioie the
appeal ancc ot the tash horn one of diphtheria
Tho lash may be absent 01 insignificant and
transient not only in veiy slight cases of
scailet le\ei, but in a few seveie cases with
serious angina These cases aie a souieo ot
much tioublc in diagnosis, ioi not infrequently
there is thick pultaceous 01 even membranous
exudation upon the fauces In such cases the
diagnosis cannot be made with ceitamty till a
Lite pcnod, \\hen the exudation has cleaied off,
leaving behind deep or e\tensi\e ulceiation, 01
until the chaiacteiistic dcsquamation has com-
menced Anj thing beyond supei final ukei ation
is uncommon m diphtheiia In tho cases oi
scailet fexei to which we aie retelling, suspicion
is olten roused betoie ulceiation or gangiene
has occuned by the megulai but continuous
pyrexia (often with deliiium), the persistence ot
the exudation (the mote remaikable if antitoxin
has been administered under the supposition ot
diphtheiia), and the tapid emaciation of the
patient The lai}nx is laiely affected in scailet
fu\ cr , w hen tins event does happen it is either
secondary to intense ceivical cell ul itis, 01 it
oceuis latei in cases where thcie is extensive
and spieading taucial ulceiation
The wntei has also known diphtheria to be
mistaken toi the following conditions — Eiy-
sipelas faticium, quinsy, entcne fevei, mumps,
vilcciatne stomatitis, thrush, syphilis (usually
tertiary ulceratiou), tuberculous uleeration ot
the fauces, heipes of the palate, phagedwna ot
the fauces (a rare disease), and not seldom,
especially m infants, dried mucus and clotted
milk adhering to the fauces With respect to
ei ywpelas fauctum and qwniy tho mistake is
usually caused by tho presence of exudation
ha\mg the appearance of meiuhianc But in
each oi these diseases the initial shivering, high
temperature, delirium, full and bounding pulse
and intense swelling, brawny m the case of
DIPHTHERIA
395
erysipelas, followed by suppuration m quinsy,
constitute a group of symptoms very different
from those of diphtheiia In enteiic fever the
error is usually mado in cases ushered m \vith
tonsillitis, but it may be due to mistaking in-
spissated mtiuih, clotted milk, etc , foi membrane
In some rare cases of mumps the cervical glands
only aio inflamed, and not the salivary glands,
but in this disease the fauces are unaffected
Careful attention to the exact natiue of the
local losions will prevent mistakes in the othei
diseases mentioned above It has been in-
cidentally stated that false membrane may be
piescnt in other diseases besides diphthciia (eg
Hcailet fevei) It is kno\vn also that local irri-
tation of a mucous smfacc by certain chemicals
and by steam may excite a membranous in
flammatiou Othci uiicio-oigamsms than the
diphtheria bacillus may pirxlucc a similar result
But without careful bactenologu al examinations
it is impossible to distinguish these conditions,
and, apait from such examinations, it is
prudent to considei all inembianous inflamma-
tion of the fauces to be diphtheiia] The same
icmaik is true oi menihianow /aiynyifit In
most eases of laivngcal diphtheiia there is no
difficulty mth rogaid to diagnosis, since it
follows 01 accompanies the iaueial foim of the
disease Hut when the after turn commences m
the larynx, 01 the Uncial lesion is slight and
tiansient, it is not easy to distinguish diphtheiial
cioup horn croup due to other causes In
some patients it is possible to obtain a \icw of
the larynx with the laryngoscope But this
means is not ahvays available, and it is useful
to know that in most children the epiglottis < an
bo biought into dncct MOTIV foi a moment by
dfpiessing the poster 101 part of the tongue , as
the epiglottis is often affected in laijnucal
diphtheiia, membrane may in some instances be
thusobscived upon its tip or anterior surface
In othet eases membrane may be toughed up
In all doubtful cases a bactenological examina-
tion should be made, a sciapmg of the mucous
membrane being taken as ncai the larynx as
possible Any njffnttoHt caMiiu/ /<iii/nyeal ofi-
sf/ ucttnn may be mistaken foi diphtheria Hut
simple laiyugitis, membranous laiyngitis, and
swellings external to the laiynx give rise to
most trouble in this respec t ( >f the latter , those
which by bulging over the laryngeal onfice
impede respiration are the most common,
namely, in childien (in whom the question of
diagnosis from diphtheria chiefly arises), post-
pharyngcal abscess, growths, and excessive
hypertrophy of the tonsils A caretul local
examination will usually clear up the case
Less commonly cases of a foreign body in the
larynx, laryngismus stridulus, and ulceration of
the larynx (especially the simple and the tuber-
culous) are \\rongly diagnosed as diphtheria,
while still more rarely croup due to paralysis of
the abductors of the vocal cords, intra-laryngoal
growths, or oxiema glottidis arc thus mistaken
The history of a doubtful case should bo caiefully
gone into , it will be observed that many of the
diseases mentioned above run a course which is
chrome compared with the duration of a case of
diphtheiia It should be remembcied that
laiyngitis maybe the first symptom of an attack
of wwtts/es Theie M then usually a high tcm-
pciaturc and frequent coughing and sneezing,
\\ith sometimes conjunctivitis and coiy/a
The diagnosis ot nasal diphtheiia must often
depend upon a bac tenological examination, smco
in many cases there is an absence of membrane
Vulval diphtheria, may be simulated by erysipelas
and noma vulva>
Diphtheiial paralysis in cases whore the
pnm/iry sore throat has been slight or over-
looked ma}/ bo mistaken foi some other, form
of peripheral nerve degeneration or neuritis,
locomotor itaxia, 01 cerebellar tumour. But
in the paialyMs following diphtheria the soft
palate is neaily al\\a}s, and ciliary muscles are
frequently affected, there is rarely \omitmg
(apait fiom c.udi.u complications), and theie
is novel optic neuiitis oi atiophy On the
othei hand there is often some disturbance of
the caidia< and r espn.it or y rhythm
PiiOGNOsis — The most impoitant factors in
piognosis are the age of the patient, the locality
of the disease, and very often the duration of the
disease before medical advice has boon sought
With ic-spcct to age the jounger the patient
the greater the* probability of a fatal termination
As to locality those cases are most fatal in which
the lar jnx is involved Cases in which the nasal
passages only arc affected are the least fatal Jit
lanngeal diphtheiia the giavest apprehension is
to be entri tamed in veiy joung children on the
one hand and adults on the other Vulval
diphtheria is usually accompanied by severe
constitutional symptoms In ocular diphtheiia
tho clnet nsk is to the eyeball
The previous duration of the1 disease before
medical advice has been taken has greater eflect
upon the prognosis in case's treated with anti-
toxin than in those not The earhei the patient
is injected with sei um the more confidently can
not only lecoveiy, but recovery without the
occimcnce '>f senous complications, especially
par al> sis, be anticipated Of partuulai symp-
toms the following die very ominous — Frequent
x omiting or rote hing, a pulse-rate falling to below
BO pci minute, marked cardiac nicgulanty,
hemorrhages fiom mucous membranes and, even
though few, into the skin and subcutaneous
tissue, suppression of urine, convulsions
Those cases in which theie is extensive and
persistent local exudation, with much albumin-
una, furnish the most se\cro*%ases of paralysis
Tho nioie widely spread the paiatysis, and the
moio rapidly it becomes geneiahsed, the greater
is the danger to life Affection of the respira-
tory muscles is especially dangerous Attacks of
396
DIPHTHERIA
syncope, frequent vomiting, and severe epigastric
pain occurring during the course of paralysis
are all grave symptoms In non-fatal cases of
paralysis recovery is always complete.
TREATMENT
By far the most satisfactoiy method is that
known as the antttojrin treatment, which we owe
chiefly to Behring and Kitasato Hence we
uhall deal with it first But before entering
into details a few facts indicative of its value
will not be out of place
The treatment was tried, in the first instance,
in Germany in 1893 , but not until after Roux's
paper at the Hygienic Congress held at Buda-
Pesth in September 1894 was it extensively
practised in other countries Since that date
there has come from all parts of the woild an
almost unanimous agreement of opinion in its
favour The icsults of the hist scries of cases
tieated in the United Kingdom AN ere brought
befoio the Clinical Society of London in Docembei
1894 by Dr. Washbourn, Mr Card, and the wntei
They showed that the moitahty of the cases in
the Eastern Hospital, Homcrton, of the Metro-
politan Asylums Board, was at once reduced to
half what it had previously been, and reported
most favourably upon the treatment, an opinion
which was fully endorsed by a Special Committee
of the Clinical Society The treatment was subse-
quently introduced into other hospitals, notably
those of the Asylums Boaid The following
figures show with what results —
CAhE-MOH'lALlTY OP DlPH IHERIA I\ THE Hos-
PIPALS OP THE METROPOLITAN AHILUMS BOARD
Year 1!
Mortality ptront I a
IVrccntapt of < ascs i '
treated with antitoxin / '
ls«M 1S9J
ivn
.«
iw
i»,
JO 4 | _"• 2
22 1
~
iTolljIj
j"
ol s
i>o 2
S02
That these losults arc not accidental may bo
shown in more than one way For instance, in
London, up to the end of 1897 at any late,
antitoxin was used but little outside the Asylums
Board Hospitals Consequently there was vei\
little lowering of the moitahty of c.ises not
admitted to those Hospitals Again, there has
been a very nvirked impiovement in the laiyn-
geal cases, among which the number included
merely upon bactcnological eudenco is veiy
small The M liter has elsewhere shown that
whereas m the pre-antitoxm days there was small
expectation of saving more than 29 per cent of
the tracheotomies, with antitoxin recoveiy is to
be looked for in no fewer than 53 per cent A
similar impiovement has taken place w ith respect
to the cases not opeiatod upon Clinically the
beneficial results of antitoxin appear as follows
the exudation dors not spread or re-form, that
which is already piesent clears off moio quickly
than in the cases not submitted to antitoxin,
and the foul nasal discharge rapidly dries up
Consequently the patient is enabled to breathe
and swallow with comfort, and his general con-
dition improves The cervical adenitis and
ccllulitis subside, and the temperature and
pulse-rate fall It is raio for the larynx to
become invaded after antitoxin has been injected,
so that extension of membrane to the lungs is
veiy much less common than it used to be
Fatal bioncho-pnoumonia is also less frequent.
Lastly, m cases treated eaily, on the first or
second day, paialysis is much less likely to
follow than m cases treated latci or without
antitoxin
Jhtns of t/te Antitoxic Tieatment — The anti-
toxic treatment in based upon the follow ing facts
It has heen cxpen mentally proved in a general
\\ ay that the blood-serum of an animal immunised
against a coitam micio-orgamsm and its toxin
has the icinarkablc propeity of acting as an
antidote to both the micto-orgamsm and the
toxin Thcio are soveial methods of producing
artificial immunity One of them consists in
meeting into an animal at mtenals of a few
davs gitidually incieising doses of tlu toxin pio-
duced by the giowth in bioth of the organism
immunity to w huh is sought Aftci a time it
\\i11 be found not only that the animal is able
to bear without ill effects the injection both of
the Ining oiganism itself and of its toxin in
laige and otheiwise fatal doses, but also that
its blood-bci nm has antidotal pioperties If a
sufficient quantity of the scium be mixed with
a fatal dose of the toxin and the mixtuic be in-
jected into a non-immunised susceptible animal,
tho lattci will not suffei from any of the ill
effects that would follow the inaction ot the
toxin alone The special application of these
gencial pimciples has been icw aided with most
success m the case of diphthena In order to
pioduee the antidotal or antitoxic serum tho
horse is the animal selected, partly because its
sixe allows a laige vicld of serum, and partly
because it beats well the process of immunisa-
tion The seinm having been obtained, the
next step is to estimate its antitoxic value
Foimerlv this was ascertained Ivy testing tho
seium with broth containing toxin, it being
assumed that amounts of different broths that
weie equal m their toxicity were also equal in
their power of combining with antitoxin to form
a harmless compound But Ehrlich has shown
that this is not the case Ho states that all
ficshlv-piepaied broths contain not only toxin,
but also a body termed by him toxone, which,
while it has tho combining, is largely wanting
in the toxic powci of toxin Further, when the
bioth is kept foi some time, part ot the toxin
becomes changed into bodies which have pro-
perties Hiimlai to those possessed by toxono,
and which arc teimed toxoids Hence, it follows
DIPHTHERIA
397
that not only do different broths vary troni one
another, but also that the same broth varies
from time to time with respect to the relative
pioportion ot itn toxic and non-toxic combining
powers The instability ot toxin has pi evented
the pioduction of a standaid toxin toi general
use Antitoxin, however, is <i much moie stable
body By a scries of experiments (which he
states can be accurately icpeated) Khrhch be-
lieves he has succeeded in eliminating the errors
duo to the varying constitution of to\m-bioth,
and has thus been able to obt.un <in antitoxin of
uniform strength This antitoxin is now used
in most laboratoiies for testing a new seitim
It is, firstly, asc 01 tamed what quantity of a
to\m produced in the usual way is neutiabscd
by onu unit of Khrhch s standaid antitoxin
Secondly, it is dctei mined how much of the
serum, ot which the antitoxic A dine is being
tested, will neutiahso this asceit.uned quantity
of toxin The definition of a "unit" is as
follows — "A serum of which Ice when mixed
with 100 times the fatal dose of toxin protects
«i gumea,-pig of about 250 gi amines weight from
de.ith within tout dajs, contains one unit per
c c " Park points out that in tins definition
toxin must be taken to mean a toxin "haxing
the characteristics of toxins in cultuie at the
height of their toxic ity "
At the picsent time seia can be obtained w hit h
contain as many as 4000 units in 8 to 10 c c
Befoie we pioceed to discuss the question of
the usage of the seium m the human subject
wo must diaw attention to one MIV impoitant
point m the expeiimental c vidence It has been
found that li an intend! be allowed to elapse
between the injection ot the toxin, and subse-
quently the antitoxin, into <i susceptible animal,
then the longei the mtenal the less effectual
will be the action ot the antitoxin, .uid, hnallj,
thcie comes an occasion when the mteival has
been made too long, and the antitoxin is injected
too late to prevent the lethal effects of the toxin
Hence it was piedicted by Behimg that the
success of the treatment would be found to
depend very largely upon the earlmess of its
application Clinical ex idoncc has amply borne
out this piedictiou The following figures, illus-
trative of tins point, are taken fiom the Statistic al
Reports of the Metropolitan Asylums Boaid —
Day of disease HJMUI which \
]iatient was admitted (lb\)4) f
or bi ought undir antitoxin (
treatment (18i>6 <>7) )
1st
13S
%
225
Non antitoxin tases l Cases
1804, all tho hos- > Deaths
pitala ) Mortality
Antitoxin t asos, ^
all the hoBiutals 1 rBIU>l,
(1695 98), with ! VffJ?,,.
Brookand Eastern fiV 11 i».
vgr*«>»l**»>
200
8
38
Further, the mortality of the cases of diph-
thona occurring among the patients convalesc-
ing from scarlet fever m the Asylums Board
Hospitals lias been reduced from an average of
BO per cent to 5 per cent Neaily the whole
of these cases aie brought under ticatmcnt on
the first or second day of then illness
Unfortunately a \eiy large pioportion of
the patients admitted to the Asylums Board
Hospitals have been ill longer than three days
What can bo done by the early administration
of antitoxin amongst even tiie pooiest patients
ticatcd in then own homes has been shown
by the Depaitment of Health foi the City of
Chicago In that city pnor to the antitoxic
period the avciage c.ise-moituhtv in hospital
and private practice was about 3*5 per cent
In October 1895 the Department undcitook
to supply antitoxin giatuitou^ly to the poor,
a medical officer being sent to administer it
immediately upon leceipt of the notification of
the case This action was at once followed by
a most cxtraordmaiy and giatitymg fall in the
casc-moitality, which was foi the period 5th
Octobei 1895 to 31st Decembei 1896, 6 r>7 per
cent, for 1897, 693, foi 1898, 733, and for
Januaiy and Febiuary 1899, 6 53
DKFAILS OK AMIIOXIV TiiKUMiiNf — Inas-
much as in diphthena the disease has already
got a stait ot the lemedy, the mortality will
piobably never be reducccl to zcio But the
above and other snnilai nguies go to show that
if antitoxic serum weie employed not latei than
the second day ot the disease the case-moitality
would not exceed 10 per cent Theiefore the
catdinal rule in the antitoxic ticatment is —
Inject eaily
If the tieatmeut is commenced on the tiist
day the dose should be 1500 units at least, it
will usually be unnecessaiy to give more than
2000 But if it be delayed, the amount must
be inci eased up to 8000 01 10,000 units, accord-
ing to the soxc-iity of the case It is advisable
to iepe.it fiom half to the \\hole hist dose
within twcnty-foui horns if the local exudation
shows no sign of lesolution With respect to
the total amount to be administered, though as
tai as the writer knows (and he has often in-
jected fiom 30,000 to 50,000 units) the limit is
set only by the volume of the sciuui that can
with convenience be injected, yet his cxpeiienco
leads him to say th.it little is to be gamed by
giving moie than 16,000 units dining the first
twenty-foui houis fiom the commencement of
the treatment But, ogam, the earlier the
treatment is begun, the less necessity will there-
be for laige and repeated doses As the more
concentrated seia aie more expensive than the
less concentrated, early treatment is more
economical
The serum is administered by injection into
the subcutaneous tissue of the flank or abdomen
The skin at the peat of injection should be-
398
DIPHTHERIA
previously washed and cleansed with some anti-
septic solution The most convenient form of
syringe is Itoux's It can be icadily taken to
pieces and boiled to rendei it aseptic , it does
not easily get out of order, and it has an in-
genious device for tightening up or loosening
the india-rubber plunger In this country it is
unnecessary to have the glass barrel or the
piston-rod graduated, since the serum is given
by the unit, and not by the cubic centnnetie 01
minim The needle is connected to the no//lc
of the syringe by a piece of rubber tubing
Caic should be taken not to inject air with the
serum All the paits of the by tinge should be
boiled immediately bcfoic use After the injec-
tion the bmall punctilio made in the skin should
be sealed with collodion For cleansing the
syringe after use cold wutei should be employed,
for if the synnge be plunged into hot water the
noodle, tul>e, and nozzle Mill become blocked
with coagulated seiuiu, the removal of which
\vill give much trouble
After-effects1- -There are certain effects due
to the serum with \vhich it is nccesbaiy to be
acquainted The most common are orythc-
matoiib rashes, inflammation of or about joints,
and abscess at the se.it of injection JUshes occui
in from 30 to 45 per cent of the cases The
most fie<juent arc erythema multiforme and
urticaria The rash usually appeals seven to
twelve days aftei the injection, but it may come
out as early .is the tust day 01 as late as the
third week In many cases there are also
febrile symptoms The rash often commences
at the se.it of injection, its duration vanes horn
a few hours to several days Aithiitis and
penarthntis occut in about G per cent of the
cases They come on about the same time as
the rash The knees, hips, shouldcis, elbo\\s,
and wnsts aie most often affected, but any of the
joints may be involved The arthritis Lists
from one to four days It is usually accom-
panied by one of the rashes above mentioned
and pyiexia Pen- 01 endocarditis docs not
occur In most cases there is no swelling of
the joints, and pain is the only symptom Veiy
often the pain is more in the large fasci.e and
tendons than the joints An abscess at the site
of injection usually means that the technique of
administration has been faultily performed, pio-
vidcd that the serum bo sterile, as it should be
But possibly in some instances of mixed infec-
tion (ey diphtheria and scailet fever) the
picsence of septic micro-organisms in the blood
determines the local suppuration. In very rare
cases other sequela: have been met with , oedema
of the scrotum with or without siight oichitis ,
and rigors, pyrexia, rapid pulse, and prostration
coming on immediately after an injection, some-
times with a rash The cases of rigors, etc,
observed by the writer have all occurred in
patients treated a second time with antitoxin in
1 See " Drug Eruptions "
a i elapse or second attack of diphtheria. The
rashes and joint-pains, but not the abscesses
(which aie caused by cocci), are due to the
seium, and not to the antitoxic principle in it,
for they can be produced by the injection of the
serum of a noimal non-immunised horse Their
occurrence is determined partly by the idiosyn-
crasy of the patient, but mostly by that of the
horse from which the serum has been obtained,
for the fiequency varies with different sera
Generally speaking, however, the larger the
volume of scrum injected the more likely is a
rash 01 aithritis to occiu Therefore with con-
centrated seia these troubles arc usually at their
minimum In most of the cases they are trivial.
It is possible that the seium also produces
tiansicnt albiiminuiia, but it docs not cause
nephritis 01 suppiession of mine The wutei
has indeed on seveial occasions injected serum
into patients, the subjects of acute or chiomc
nephritis, without any ill effects
Serum \vill lemain efficient foi several mouths,
but it is advisable not to keep it for more than
a few weeks, as theie is leason to believe that
in some instances the antitoxic value becomes
lowcied It should be kept in a cool and dark
place Never keep a bottle of serum which has
been uncoikcd
Local Treatment — In addition to antitoxin
local tieatment is advisable in most cases, in
oidcr to remo\e the exudation and render cleai
the obstiuctcd faucial and nasal passages Foi
this pin po&c the aftectcd legions should be
frequently flushed out with warm watei, or a
satuiated solution of boiacic acid, 01 the follow-
ing solution, Sodu bicaib r>J . sodn biboi ,~J ,
sodii chlond ;>H, potassn (hloiat 3ss, tinct
la valid comp 5j , aq ad Oj The flushing out
is best accomplished by means of a Higyinson's
or a ball syringe But it, as is often the case,
the child violently resists all attempts at local
irrigation, it is ad\isablc not to peisist, ioi such
attempts only exhaust the patient and do moie
haim than good The use of solutions contain-
ing such agents as chlonne, sulphurous or
caibohc acid, which act as irritants to the
mucous membranes, aie, in the w liter's opinion,
undesirable, except in very foul and septic cases
The best local treatment foi ocular, vulval,
and cutaneous diphtheria is fiequcnt irrigations
and warm fomentations of boratic acid solution
When laryngcal symptoms arise, the patient
should be placed in a room, 01, if in a ward, a
tent, in which the an is kept saturated with the
waim vapour of water by a steam-kettle In
many cases the symptoms will, under the anti-
toxin treatment, subside without any question
of operative interference arising But should
thcic be cyanosis, restlessness, much recession
of the chest-walls (which leads to pulmonary
collapse), or frequently recurring acute attacks
of dyspnoea, relief must be affoided by intuba-
tion or tracheotomy
DIPHTHEKIA
399
Intubation and Tracheotomy — hi this country
intubation in diphthcua lias never attained to
the favour that has been accorded it in the
United States and on the Continent, where since
the introduction of the antitoxin treatment it
has almost superseded tracheotomy This differ-
ence in practice is veiy largely due, in the
writer's opinion, partly to the fact that abioad
many cases ate mtubatcd which heie arc not
opeiated upon in any way, and indeed recover
without any need for operation, and partly to
the fact that the patients arc brought under
the antitoxin treatment at an earlier stage of
the disease than m this country The advan-
tages urged on behalf of intubation ai c th.it a
cutting operation is avoided, togethei with all
the links of tracheotomy (emphysema, luemor-
i hage, broncho-pneumonia, etc ) , lh.it no an.cs
thctic is required , that especially if repeated it
acts mechanically m clearing out the larynx by
the removal of membrane, and that its results
are more successful than those of tiacheotoni}
The probable cause of the last statement is
alluded to aho\e On the other hand, an m-
tubatcd child must ne\or be left out of immedi-
ate leach ot a medical man , the tube may be
suddenly coughed out, and the urgent symptoms
of obstiuction recur, 01 the tube may become
blocked while in the larynx The nurse is
usually quite helpless should eithei of these
events happen The tube sometimes sets up
ulceiation of the lai\ n\ Bungling and fon iblc
attempts to introduce the tube will damage the
larynx, and cause false passages The w liter
has seen all these accidents except the last
With respect to difficulty m execution theie is
little, if any, difteiemc between intubation and
tiacheotomy The writei's cxpenence leads
him to formulate the following piopositions —
In a cousidciable projKution ot cases intubation
is eithei inadmissible or inexpedient It is
admissible m UNO classes of case- those in which
the patients, when brought for treatment, aic
in ejittenui, from suffocation, and those whcie
theio is very abundant faucial membrane It
is inexpedient in toxic cases in which theie is
little or no hope of the patient's recovery
Here tracheotomy should be performed to ease
the pitient's last moments Otheiwiso intuba-
tion should be practised The intubation tube
should be taken out at the end of two days
If it has then to be replaced it should bo taken
out at the end of another two days, and if
necessary again replaced If, at the end of two
more days, \\ithdiawal of the tube still leaves
the patient in disticss, it is best to trachco-
tonnse. In cases where the tube is repeatedly
coughed out it is not advisable to mtubate
more than six or seven times Lastly, if there
is evidence of extension of membrane below the
larynx, tracheotomy is to be preferred to in-
tubation It is stated by some writers that
membrane is coughed up through the intubation
tube, but the writer has ne\er met with such
a case None of the cases he has had under
observation, in which there was membrane
below the laiynx, ha\e done well with intuba-
tion, but have come sooner or latei to tiacheo-
tomy. In pnvate piactice tracheotomy is
certainly to be preferred to intubation , and the
operation should be resoitcd to earlier than m
hospital practice, where both operator and in-
struments are at hand for any emergency For
the details of the two operations, etc., the reader
is referred to the articles dealing with them
(*SVr "Intubation," "Tiacheotomy")
Geneial, Dietetic, and Aledtcitwl Treatment —
Dining the acute stage of diphtheria the patient
should be kept at rest in bed, and he should
not be allowed to get up for some days aftei the
disappearance of the local exudation, and only
then if the cu dilation is normal and theie is no
sign of panlysis (Uses that picsent symptoms
of tox.'uma (allnmmiiu la, >omitmg, frequent
and megular pulse, etc ) require most careful
watching Seiious and e\en fatal attacks of
synco]K3 may be induced by allowing a patient
to get up and walk about too soon Caution
has to be exercised in letting the patient even
sit up in bed
The diet calls foi no special remark It
should be such as the patient can take with
comfort, frequently admiinsteicd in small
quantities at a time Repeated \omitmg at
any stage of the disease is best met by rectal
feeding Alcohol and sti \chnme aie useful in
the late but not the call} caidiac failure, moie
especially m attac ks of syncope The aikcmui,
too, often following the disease usually calls
tor non in some foim Fiesh an and sunshine
are Aei} necessaiy foi lapid comalcsccncc
At the tust sign of paial}sis (nasal \oicc,
i egurgitation of food through the nose, etc ) the
patient, if up, should be again confined to bed
If aftei a week 01 ten dajs the palsy icmains
limited, he may be allowed, up again, but should
be w aincd against or pic\ented fiom exciting
himself Any achance of the paialysis is an
indication foi further rest In tact, complete
lest is essential m all cases where the palsy is
nt all widely spiead In such cases all excite-
ment (e </ \isits from lelations and friends)
should .is fai as possible be avoided When the
icspiratory muscles aic affected the foot of the
bed should be raised to allow the bronchial
sccictiou to escape into the mouth, and to
prevent the salmi tiicklmg thiough the laiynx
into the bronchi, otheiwise the lungs become
blocked to such a dcgiee as to lead to a fatal
lesult Extract of belladonna, J giam every
three or four hours, is recommended m older to
dimmish the amount of these secretions. A
cough during swallowing is always an indication
to administer nourishment by means of a tube
passed through the nose into the stomach
Isolatwnand Disinfection — The patient suffer-
400
DIPHTHERIA
ing from diphtheria should be isolated. If he
is kept at home all precautions should be taken
to prevent the transmission of infection to others
As a rule, ho should be kept in isolation for at
least four weeks fiom the commencement of the
illness. In the case of children the wnter
prefers isolation of at least six weekn Even
then they should not be allowed to mingle with
healthy childicn at the end of that time if
there is any dischaige from the nose or inflam-
matory condition ot the fauces The so-called
" return " cases are not so common in connection
with this disease as \\ith bcarlet fo\ei It has
been stated by 1'aik and otheis that as a rule
the diphtheria bacilli arc absent from the fauces
three weeks after the dis.ippear.incc of the
exudation But in the wntcr's e\peiience ca^cs
have not infrequently ocumcd in which the
organism has been piesent in a virulent form
for sevcial wucks or months aftci an attack of
diphthciia, and that in spite of local antiseptic
treatment The question anses \\hcthor Mich
a patient is to be kept isolated an long as the
bacilli arc piosent On this point the wiitei
can only say tha* he has not detained in
hospital such cases for a longer peiiod than
three months, and some even ior a shoiloi
time, and to the best of his knowledge no
secondary or " return " cases have been caused
by such patients alter their discharge At the
same time in letting such patients out ot isola-
tion it is advisable to impress upon the paieuts
or friends the wisdom of keeping the i ceo \eied
patient as far as possible to himself with lespet t
to other children (eg not sleep with child i en,
kiss them, etc ), and to be on the look-out foi
any icciudcscouce of soie throat
Prophylaxis — Another question which arises
in the prophylaxis of diphtheria is Should
antitoxin bo employed as a preventive agent?
As a rule the writer would answer, No The
prophylactic powei of antitoxin does not last
for more than three weeks, if so long But
there aio a few well -reported and authentic
instances wheio a case of diphtheria having
occuried in an institution for childien (hospital,
school, etc ), and other cases having followed at
intervals, the outbreak has been cut short
apparently by submitting the leinaming children
to the injection of antitoxin Therefore in
special instances this measure is worth a tnal
It is not necessary when injecting antitoxin as a
prophylactic to give more than 600 units
Dlphthonffla or Dlpthonla.—
The production of two notes of different pitch,
a form of vocal disturbance met with in some
morbid states of the vocal cords See LARYNX,
BEN ION GROWTH^ OF (Clinical Features)
DlplaCUSlS* — An incorrect hearing, two
tones being heard when one only is produced
See AUDITOUY NERVE AND LABYRINTH (General
Diagnosis), EAR, MIDDLE, CHRONIC NON-SUP-
FURATI\E DISEASE (Hyj.erttophic Catarrh, Dis-
harmomc Diplacusis).
DlplOgUU — Paialysis of corresponding
paits on both sides of the body, e<j of both
legs, of both arms, or of both sides of the face
See PARALYSIS (Cerebral fitplegta). See aim
MENTAL DEFICIENCY (Accidental, Acquired, Trau-
matic)
Dipleural.— Bilateral ((5i &'$, double,
, the side)
DEplOCephalllS. See DICRPHALUH
DiplOCOCCUS. — A double micrococcus or
a pair ot micrococu joined together as a dumb-
bell-shaped organism, such as the D wtni-
uhuti* menin(/'ti({)*t the D aUncnnt> ainplw*,
etc 8<e AC*,K (Acne Vu/t/ttris, Mtcio~0i<janis?ns) ,
MENINOHIS, EPIDEMIC CEREIIUO - SPINAL (liai-
iolw/y), Now-,, ACCESHUHI SINUSES, INFLAM-
MATION* (Jtartei ifdw/y, Dtpluroci uv Pneumonia*) ,
SUFFI iiAiioN (Etiology, D'ploiw i ui Pneumonia1),
TUBERCULOSIS (Mued Infection in)
DiplOCOrla. — Double pupil, e<j that due
to subdivision of the pupil by a baud of pei
sisteiit pupillaiy membrane, polycona
DIplOG — The cancellated substance found
between the inner and outei tables of compact
tissue of the l)on es of the cranium , it contains
thin-walled, blanching, valveless \cniH, and it
is absent in the oibital plates of the frontal and
the cribtifoim plate of the ethmoid bone
DiplOgenOSlS. — The foimation of a
double monster or polysomatous teraton , diplo-
toratology
Diploma* — A document gianted by a
uuiveisity 01 college, "testifying to a degiee
taken by a peiwon, and confciiing upon him the
ni>hts and privileges of such a d eg ice," e g to
pi act iso medicine "The gi anting of diplomas
by universities or other learned bodies piocecds
011 the supposition th.it tho public require some
assistance to their judgment in the choice of
piofesHional services, and that such an official
scrutiny into the qualifications of practitioners
is a useful security against the imposture or in-
competent y of meie pretenders to skill " (lllustr.
quot in Murray's New English Dictionary)
Dlplomyelia. — A double condition, duo
to antenatal causes, of the spinal cord , dia-
stematomyelia
DIplopia.— The seeing of single objects
as double , double vision , it may bo binocular,
disappearing when one eye is shut, or (rarely)
uniocular or monocular , when it is binocular it
may be homonymous (the position of the double
images corresponding to the position of the
eyes), or hcteronymous or crossed (the left
DIPLOPIA
401
image corresponding to the right eye, and the
right image to the loft eye) , a common cause
IB squint. See HYSTERIA (Oculw Symptom^ ,
LACRIMAL APPARATUS (Diseases of Glantl, Chtomc
Adenitis), MYASTIIKMA GUAMB (Syniptomato-
toyy), NONE, ACCESSORY SINUSES, INFLAMMATION
(DifH/nwus, Eye-tiymj>tomv), OCULAR MUSCLES,
AFFECTIONS (J'arafym), SriunisMUs, SYPHILIS
(Tertiary, Eye - ftymptomi) , Tmnoii) <»LANI>,
MEDICAL (IS nyihthalnuc fVW/e,
DiplOSOmuS. — A double monst(r 01
united twins in \\huh there .tie two bodies, the
heads being moic 01 less fused
. — The science of
double monstcis, then chaiacteis, classification,
and mode of production
DiprOSOpUS.— The teiatoionical cimdi-
tion in which theie «ue two laces, moio or less
fused into oiu» , th«'ic may bo fom eyes, 01
thieo (one of which is ,i fused double eje), or
two, and foui eais ot thiee
Dipsesis.— Kvessive thust ((h
tin ist)
Dipsomania.
SYMPIOMS
NATURE AND I'MHOLOM
DIAGNOSIS AND KrroLo<,v
THF \ i MFN i
401
402
402
403
«SVf (if SO AlX'OlinriC I \s\\M\ (Dtjlllttinn) ,
HYPNOTISM (ThtHlfttUtU iVxfS, DtJWHUUlHt) ,
INS \\ITY, N \IUHK AM) S\M1?10MH (///t/JM/M a/id
(Msrssioii, Dif Banian in")
DKFIXITIOV — Dipsomania is «in elaboiate
idiosynciasy tovvaids alcohol with occasional
paio\ysmal and inesistible impulses to dunk
excessively
SIMPIOMS - Dipsomania is, pat iicellime, the
alcoholic disease oi good people Both men and
women aie the victims of it, but women less
fiequently The idiosvwi isj which it betokens
is a congenital incquilihiium, and oums genei-
ally, but not always, in obviously neurotic sub-
jects The paroxysmal phase usuallv develops
for the fust time in the second half of adoles-
cence, but may occur any time aflci the patient
has tasted alcohol and lias discovered his sus-
ceptibility to it True dipsomania is compaia-
tively rare
One cannot insist too stiongly upon the fact
that dipsomania is not the development of an
alcoholic habit It is much more truly the
exact opposite — an abiupt and occasional depar-
ture from habit Wo hav e to suppose — though
we cannot always obtain evidence of it- -that
the patient, on having tasted alcohol, has been
aware ot an excessive and peculiar reaction to
it Not that he has become rapidly intoxicated,
or even that anything which an onlooker might
observe has occuried, but that the patient has
VOL II
discovered in alcohol a source oi acute, expansm
pleasuie If he T>c a \cry stiong man, the
paioxysmal impulse may be indefinitely post-
poned In my opinion there ate quite a numbei
of patients in whom the disease never becomes
actual They carefully avoid what is to them
a \crydangerous indulgence Voie frequently,
however, the patient does not deny hunseli so
strictly, and occasional dchbuate indulgences
strengthen, m his mind, the impiession of
dchglit in drinking Some <asrs have been
doocnbed in v\hich, almost from the first, theie
was no etfoctivc check upon dunking, but the
usual thuiu is foi the patient to legist his vice
sii(C(ssfull^ for .1 considerable penod Sooner
oi latei, lim\cver, in typical c.is( s, the paio\ysmal
phase occui - a quite unique and unmistakable
development The usual clnut il pictuie is as
follows —
On so' m occasion of fatigue — tow aids the end
oi a bus^ siason, und< i the dtpicssion of bodily
illness <n mental htn-ss, dining lactation, 01 in
the leattion which OCLUIS in busy people who*
suddenly imd themselves at leisuie— something
Aeiy like an attack ot acute melancholia sets in
The patient goes otl his sleep and loses appetite,
becomes cos>ti\e, and has a diy skin, and diy,
tuned tongue, sutlers some uudiac discomtoit
01 pain, and some mild demee ot d\spna.'a The
chaiacteiistic ieehn» vvhiih peisists is one of
acute sippiehension This piehminaiy stajie is
shoit — often not more than horn si\ to foity-
eiight houis Then occuis the akoholic obses-
sion The patient becomes avv.ue that the idea
oi dunking is occmimi; to his mind with un-
pleasant frequency Do wh.it he will to draw
his attention to sane piojects, In* finds tlu» task
impossible, ind, a irvv houis latti, the alcoholic
idea is constant in his mind, and Ins inteiest in
othei things almost <omphtcly in abeyance
Still acutelv .ippieheusive, the p«itient now finds
himself sti lulling against a tviannous impulse
The stano of obsession is past With some
fugitive thoughts ot what he is dntting ,'ivvay
fi om — home , business, honom — the patient
lesions himself to the immanence of the alcoholic
idea Then he passes tiom the contemplatn e
l<> I he pui])oselul suuuestion His stiugglo now
is not v\ith liis thoiiuhts, but with hih impulse
lie is entnely <md vainly o(( upied in tiymg to
compel himself to sit still 01 to go to a sate
place, in tiymg to resist the ungovernable
impulse to go to the wine eellai 01 the public-
house
This may seem a common occuiience, a meie
account ot what temptation is to every man
who tries to bieak a bad habit But no one
who has seen a dipsomaniac in the phase of
impulse will easily foigct the pftturo, 01 confuse
it \v ith the ordinary f eatui es of alcoholism The
geneial impiession suggests the idea of an
instinct One is reminded of how animals
behave undei the intense excitement of the
26
402
DIPSOMANIA
reproductive or the maternal instinct, the in-
stinctive fear for a natural enemy, the instinctive
hunger for a natural prey The whole man is
changed His face is haid and act, tull of fear,
evidently bent upon something — either a way
of escape or a means of .satisfying his ciavmg, —
his muscles ate twitching, ho is restless and
under gicat bodily disticss, his respiration is
panting, his pulse, quick, his skin hot, Ins tongue
thy and patched Actual thirst is acute, but,
though the patient drinks laige quantities of
bland liquid, satisfaction docs not follow, and
cannot, except by intoxication The chaiactei-
istic termination oi the attack is by some degree
of coma This the patient accomplishes rapidly
once he resigns himself to it And now it is
chaiuctcristic th.it lie dunks alcoholic liquor as
a \vatei-staivcd m.ui dunks watei — not with
any linget ing plcasiue, but in dienchmg doses.
At this stage, when the patient has begun to
dunk, volition piactically coaxes to exist except
for pui poses of di inking, and he w dangeiou-*
to hnnselt and to othcis Any one \\ ho ti les to
thwait him may bo Molently assaulted, the
most dangoious le its of escape fioiu confinement
may be attempted , and even extieme acts of
unmoiality will not daunt a patient whose mind
is made up
By degiees — olten not so quickly as would
happen in a noim.il man — some degiee ot coma
follows Unless tho hquoi has been diluted
theio is nsk ot alcoholic poisoning When the
patient is so comatose as to be oblivious oi .ill
else, he will still leach out foi dunk and pout
it down his thioat It is not usual tor positive,
alcoholic symptoms — e\citement, dehnum, con-
vulsions, and such like — to be pionnncnt m the
first bout Tlu» patient at last sleeps, and
awakes, as a mle, feeling better Veiy often,
howe\ei, thcxc is only an mleival of peace, and
relapses axo xei> common Piobably after a
week 01 ten days of lepeated bouts tho patient
recoveis bv piostiation, a condition of collapse
in which he is fiee fiom tho alcoholic suggestion,
or iiu'ins del n mm tiemcns 01 insanity It is
important to note that patients who have been
prevented smvive a paioxysm with a sclt-i expect
which has been letamed at the cost of organic
satisfaction, and aie liable to have rccuiicnt
paroxysms Those who dunk, while they may
be plunged, when they leoover, into remoise-
ful dif-ticss, have a souse of satiety which is, to
some extent, a safeguaid
The subsequent history of cases is vaiicd
<ioneially speaking, paioxysms are not poiwxlic,
but aie moie tiuthfully to be described as
occasional Some cases become lapidly woise ,
others seems to pass thiough one paroxysm aftei
uuothci withou't much depicciatiou Cncum-
sUuices \vhich have been the occasion of a
paroxysm aie apt, if they recur, to occasion
another and another — piobably by suggestion
But many cases which have been treated judi-
ciously outgrow their idiosyncrasy, or at least
escape its paroxysmal phases
NATUHK AND PATHOLOGY. — The pathology of
dipsomania is quite unknown To understand
the condition it is helpful to consider the two
phases of the disease — tho idiosynciasy which
piedisposes to it, and tho paioxysm which ex-
presses it 1 would revert again to the analog}'
oi a biute instinct There is something quite
unusual m the patient's leaction to alcohol,
compatible pcihaps to the constitutional effects
of chaiaetenstic odouis upon the lower animals
We perhaps go too far in deseiibmg the leaction
as pleasant , but it must obviously be at least
attiactivc As a mattei of fact, howevei, tho
patient is often not sure whether he more likes
oi dieads the experience which follows upon a
mild indulgence Tho condition ot the patient
in the subsequent stage — the stage of lesistance
— must also be mtctpieted in the light of his
pievious expenence Piobably the patient's
imagination is mine habitn,ill y imdei the influ-
ence of the alcoholic idea than he confesses.
The paioxysm may be vanously explained
Pcihaps it is a cusis — the culmination of a
pio^icssue, alt oholie psychosis compatible to
an epilepsy Or it may simply bo tint pi i sons
who have the alcoholic inequilibiium which
dipsomania betokens aie liable to occasional
rerun cut attacks oi acute melancholia, and
th.it then the alcoholic suggestion which has
been suppiessed obtains a rapid and complete
asecndcncj' A\ hatevei the moibid piocess be
which we may suppose to underlie the pheno-
menon, dipsomania is ancr\ ons condition in \vlnch
theie is (1) a nenous state m nhu b al<oholu
stimulation is po\veifully suggestive, (3) occa-
sional conditions in which the alcoholic neurosis
assumes an cpileptoid intensity, oi in \\ Inch the
volitional functions general lv arc so led need as
to admit of its lapicl development The force-
fulness of the impulse is nothing new We are
familiar with the same kind ot thing in other
pathological states — pyiomaina, nymphomania,
cte , and, as 1 have said, in biute instinct
But no one has a satisfactory explanation of
such phenomena
DIAGNOSIS — It is the common custom to call
all manner of cases by the name dipsomania
which have not much in common with it except
just the bouts of excessive dunking Such a
piac'tu'c may not be of very evil consequence,
but it is fax from exact True dipsomania can-
not easily be mistaken The condition is con-
stitutional and native, it does not develop in
consequence of alcoholic habits, and it has
dramatic features which are impressive and
unique. Some writers speak of pseudo-dipso-
manias, but it seems to me bettci to consider
these as varieties of alcoholism Features which
charac tense dipsomania — the unusual icaction,
the occasional crisis, the forceful impulse— may
each of them occur in alcoholism But unless
DIPSOMANIA
40$
the patient manifests these symptoms inde-
pendently of persistent alcoholic habits, he IB
not a dipsomaniac Moicovci, in dipsomania
the symptoms common to alcoholism (qv) do
not abound Apuit from these coses of alcohol-
ism dipsomania is, as I have said, rare
ETIOLOUI — Dipsomania IH not hereditary in j
the strict sense It is an inequilihiium which
may occui in any neuropathic family, and it may I
be the first instance, in a long lace, of nervous
depieciation. The occasions of paioxysmal im-
pulse aie of much moie piactical impoitancc
than aie the constitutional causes of the idio-
syncrasy These have aheady been indicated
Adolescence is of the first importance , m oldei
men, the picclimaitciic stage \\hen business is
often excessive, and, in \\omen, the late puei-
peial and l.ictational period As in other
neuroses, the pciiodicity of the paroxysms is
more inaikcd in women than in men
TREATMENT — The tiealmont of dipsomania
is palliative as legards tlie idiosyncrasy, and
pioventne as icgaids the paiovjsni In othei
words, the patient should be treated .is nemotic,
and discipline and hjgieue should be made to
rnimstei to stability The tieatment usually
pie&ciibed icfeis almost cntncly to the pie'ven-
tion oi dunking when a paioxysm has occuried
It is questionable it that is impoitant. It is
much more valuable to anticipate the crisis
When a patient is expecting an attack, actrse
steps should be taken to outflank it An abi upt
and sudden readjustment ot the whole circum-
stances of the patient is called foi always m
the dnectiun of iccupeiation of eneigy Change*
is the fust essential , and it must be borne in
mind th.it \eiy often an unusual activity is
lecuperaiive If the paioxysm has not been
foiestalled, and the physician is called to a case
in which the stage1 of obsession 01 that of im-
pulse has been leached, he must de\otc himself
to the least huitful satisfaction of the ciave
An enema should be admimsteicd, the stomach
should be washed out, and sedatives or intoxi-
cants should be admimsteicd by the tube* At
the same time nutrients should be added, and
saline 01 other aperients It must be the
physician's aim to induce hypnosis as speedily
as possible, and at the same time to furthoi
elimination The patient must, in no case, be
told what has been administered Hypnotism
is very useful if resorted to soon enough, but is
not likely to be applicable m the paroxysmal
stage
DlpSOptlObiCU — " Fanatic abstinence
from intoxicating liquors" See INSANITY,
NATURE AND SYMPTOMS (Insane Defects of In-
hibition)
Diptera. See MYIASIS (Myums Intestt-
nalis, Diptera Larvae) , PARASITES (Insects,
Diptera).
Dl pU8.— Double foot, as in cases in which
theie are from seven to nine digits on one foot,
along with indications that the foot la really two
feet more or less completely fused ; the trim
dipus is also given to double monsters in which
there are only two feet (instead of thico or
four)
DlpygUS. — That type of double mon-
strosity or united twins in which the lower end
of the trunk is double (double sacrum)
Dlpylidium Can I num. See PAKA-
SITEM (Ceitfxfea, Tvpnm Camna) — A common
intestinal parasite in the dog, the ripe pro-
glottides have the shape of melon seeds, hence
the synon\m<ms name Tit-nm cunnneuna some-
times guon to it , the laivoi develop in the lice
and ileas of the dog
Direct Action. - The effect which a
ding produces on an oigan such as the kidney
f i om contact, local action (we PHARMACOLOGY)
in contiast to mdnect action, \\lnch is a
secondaiy effect
Direct Tracts. AVe SPIN\L CORD (Ana-
tomical C(>nwdeniti<tH\) , Fmsioiom, N&HXOUH
SihrbM (Njunal Coid, Conductm*/ Path*)
Director. — Vn mstiument, yiooved on
one side, foi dnecting the comse of a knife or
scissors m making an incision into an oigan, an
abscess, 01 a cyst in the midst of important
structuies which it is \eiy desnablc not to
\vound
DirrhinUS. — A iaie foiin of monstiosity
in which theie are two noses (liallantyne's Ante-
natal Pathology, vol n p 397)
Dirt-Eating. to PKA
DiSaCCharidS. — Double sugai s, e </
maltose, two glucose molecules pol^meiisc to
toim one maltose molec ule See PHYSIOLOGY,
FOOD AND DioEsrioN (
DisaSSlmilation.— Thetiansformation
of assimilated substances in the body into less
complex compounds with liberation of eneijry ,
cutabohsm 01 katabohsm , downward meta-
bolism Nt< Pn\siou)o^, PROTOPLASM (Meta-
ii Kataltoln, Chan<ie*>)
DisaSSOClation.— The breaking up of
a complex molecule into simpler ones at a
certain elevation of temperature (temperature
of disassncmtiori), with reunion of the simpler
molecules after waids when the temperature
falls
•
DISC. — Any lounded, plate-like body, but
especially the optic disc (entrance of optio nerve,
or blind-spot), blood discs (red blood corpuscles),
Hoioman's and Hensen's discs (the discs into
404
DISC
which a muscular fibre can bo split up), mtet-
vertebral discs (mteneitobral cartilages in the
Bpme), tactile dncs, etc fiee UETINA AND OPTIC
NERVE (Inflammation of Optic Nervet " Choked
/>wc"), etc
Discharge. — A secretion 01 excietion, 01
the act by which it is ejected from the body or
organ in which it is formed, ft/ the lochial
discharge (tee PUKIIPBKIUM, PHYSIOLOGY, Lwhia),
or the escape of <u cumulated encigy, e y neivous
energy in noimal ceiebial actions 01 m epileptic
fits (see PiiiMioixj'A, NKIUOUS S\,SIKM, Uettbtum,
DiSClSSlOII. — The musing 01 cutting into
of the capsulo of the lens in cat.iraet opei ations,
or the division of the cervix iiteii fioni uithni
outwards
DISCI I nation, *SVe COM i IVATIOV
Discrete. — When the spot*. 01 pustules
of a skin disease, e y sui«illpo\, aio separate and
not coalescent, they aie called disci etc (dt^cei neie,
to separate) *SVf SMALLPOX (C I muni \'atitfic^
Vat loloid]
Dlscromatopsia. &•> ihwiiKoM\-
TOPSIA
DISCUS.— A disc, espeeiall> the discus pio- i
hgerus oi the Graafian follicles of the o\aiy ,
the cumulus umhgcriis or discus Mtellmus
See GENXRVTION, FEMALE Our, \vs OK (Ovane^
Microscopic Appeal ance*)
DlSCUtlentS. — Medic ines, applications,
01 methods of treatment ha^ 1111; as then object
the dissipation, dispersion, 01 icsolution of
swellings, effusions, turnouts, 01 congestions,
resolvents , commonly employed dissentients are
fomentations, fiution, bhsteis, iodine, and
mercui}
Disease. — A distuibed, disoideied, 01
deranged state ot the bodily functions, due
gencially to stiuctui.il alteiations in some or
all of the 01 gaus 01 tissues (stnutural diseases),
but caused sometimes by conditions accom-
panied by no appieciablo (or }et appieciated)
lesions (tunctioiud diseases); diseases are also
classified as congenital, constitutional, acute,
chronic, contagious, idiopathic, general, local,
nervous, organic, stymotic, etc , etc Sometimes
the name of the medical nun who first desciibed
a malady is given to it, e </ — Addiwrfs Disease,
Albert's (Fungoid Mycosis), Aran - Dwhenne'*
(Progressive Muscular Atiophy), Batfowl
((Jhloroma), Banti's (Splenic Antenna), Jjatedow's
(Exophthalmic Goitre), Jiaun's(R\icG&\ Psoriasis),
Jieaid's (Neurasthenia), Jlef/bie't. (E^ophthalnna),
JReigel'i, (Tnchorrhoxis Nodosa), BeWs (Typho-
mauia), Eelz's (Ulceiation of Lips), JBergeton's
(Chorea), JinyWs (Nephntis), BM* (Fatty
Degeneration of New-born Infant), Cat rum's
(Verruga Pcruana), Charcofs (Amyotrophic
Ijateral Sclerosis), Concato's (Polyorrhomemtis,
Chronic Peiitomtis), Comgan'v (Aortic Incom-
petence), Cotugno's (Sciatica), Cruveilhi&t'n
(Gastric Ulcer or Progressive Muscular Atrophy),
Darter's (Acne), Dercum's (Adiposis Dolorosa),
Devergids (Lichen Ilubci), Dt tatter's (Paroxysmal
Hiemoglobmuna), Dublin's (Electric Choica),
Duchenne'i (Pscudohypci trophic Paralysis),
Duhnng's (Dermatitis Herpetiformis), J£ich<>tedt\
(Deiniatomycosis Fuiimacca), Fede'a (Subhngual
Fibroma), Flaiam's (Exophthalmic Goitre),
Fothen/ilFs (Tngeminal Neui.ilgia), Fnedt eich't>
( Heredit<iiy Ata\ia on Paiamyoclonus Multiplex),
(feihet't (Kndcmic Paralytic Veitigo), Gille** dt
la ToMettt't (Iinpulsno Tic), (riovannint^
(Nodulai Disease of Han), (MnartVs (Entcro-
ptosis), (Jtanrhn'i (Splcnopneumonia), dhavef*
( Exophthalmic (ioitre), Gull's (Myxocdcma of
\dults), Hammond** (Athetosis), IJanot'* (Hypei-
tiophic Hepatic Cnrhosis with Jaundice), Ilai-
l?y\ (Paio\ysmal Ha^moglobmuiia), I/etna1*
(Erythema E\sudati\um Multifoime), Henocb'*
(Neivous Piupura \vith Tolic), ffttvhynwtfb
( Dilatation of Colon, Megaroloii), Hotlylm\
| (Pseudoleucotyth.emia), /Jodaia's (Vanety oi
Tnchonhevis Nodosti), IIu<jmei\ (Uteimc Fib-
I toids), JJuivtinydoii'* (Chronic Chorea), /wiA/er'i
(Multiple MyelosaicomaU), A'ri/wti'j, (Xerodeirna
Pigmcntosum), 7u idiab&\ (Veitigo with Sensot}
Illusions, Caidiac lint.ibihty, etc ), Korwkoff't*
(Polyneuntic Psychosis), Ldtuht/'s (Acute
Ascending Paralysis), Lebet\ (Hereditary Optic
Atiophy), Little's ((Congenital Musculai Rigidity,
Spastic Paralysis of Infants), jl/o/t/o'* (Pen-
vagmitis Simplex), ^fnla^'>t~s ((Jystic Testicle),
Marie '& (Aciomc^aly), Jfrtueie's (Anditoi}
Vertigo), Mikvlic^( Enlargement \vith Scleiosis
of lachrymal and Sahvaiy (ilands), A/otton'*
(Metataisalgia), J/www'* (Vanety of S^imifo-
myeha 01 Leprosy), Munnhmtyfi't (Piogicssivt-
Ossifying Polymyositis), Ot>!ei '/(( !hi omc Cyanosis
\\ ith Polyc} th.emia and Enlarged Spleen), Payet\
(Osteitis Deformans), Pwjrfi disease of Nipjdc
(Cancel (?) of Nipple), Patlinton's (Paialysis
A£»itans), Part oft (Syphilitic 1'seudopaialjsis),
Pany't (Exophthalmic Goitre), Pavy't (Inter-
mittent Albuminuna), Pot ft (Spinal Canes),
QwncKe^ (Angioneurotic Oedema), Raywtud\
(Locdl Asphyxia \vith Symnietncal Gangrene),
JteiUmgfmuKen's, von (Genciahsed Neuionbioma-
tosis), Reclurf (Cystic Disease of Mamma),
Keichma'nn'a (Nervous Dyspepsia with Super-
secretion), Riga's (Subhngual Fibroma), Hitter's
(Dermatitis Exfoliativa Ncouatorum), Rivolta\
(Actmomycosis), Sachs' (Amaurotic Family
Idiocy), Savdl's (Epidemic Eczema), Schonleirft
(Purpura llhcumatica), Stokes-Adamx' (Angina
Pectoris with Bradycardia or Paroxysmal Brady
cardia), Sydenham's (Chorea), Talma's (Myotoma
Acquisita), Thomson's (Myotoma), Thornwaltft
(Cystic Disease of Pharyngeal Tonsil), Toniase/h't
(Quinine Fever), Wardrop's (Malignant Onychia)
DISEASE
405
Weil's (Epidemic Catarrhal Jaundice), WerliioJ 's
(Purpura H&cmorrhagica), Whytt'* (Hydro-
cephalus), Wilton's (Generalised Exfohativo
Dermatitis), WiTuHel'i (Epidemic HuMiioglobin-
nna Neonatorum), Wodlez's (Primary Congestion
of the Lungs)
Disinfection.
I WAYS AND MEANS op INFECTION 403
A Way* of Imp eti 405
B Wayiof JStite^ 405
0 Pettodv of Incubation and hi
fectivity 406
II DISINFECTION AND DISINFECTANTS 407
GENERAL 407
SPECIAL 407
HEAT 40K
CHEMICAL DIAIN»BCIAMH —
Oxyf/eni, /faloyenv, Ovule* ot
Nittwjen, Alkalies, Acids, Metal-
he Salt*, J'/ienots, Formic Alde-
hyd 408
III PRACTICAL DISINFECTION 110
GENERAL 110
{SPECIAL 411
,SVe alto ASEITIC TREATMENT oi- WOUNDS ,
AMISEITIC SURGERY AND ANTISEPTIC s , CHOLERA,
En DEM ic (Pt ojthylaxt^) , GLANDERS (I'teven-
flfm) , Qu \RANTTNE , SEWAGE AND 1)RAINA(>E ,
ctr
I WAIS AND MEANS oi< INHS.CIION
(A) Wayi of Inf/tei,8 — Infectious diseases
may be communicated by inoculation, by con-
tact or association with the sick , by v ehicleb,
as excreta or watei, etc, 01 dothmg and othei
articles contaminated theie\vith, and containing
01 con\ eying the imciobes or their spoies , by
the bites, otc , of insects, and by i esidenu* in
infected localities
The modes of ingress of the miciobos into the
fluids of tho body may be distinguished as
(1) inoculation , (2) absorption , (3) inhalation ,
and (4) mgestion Some diseases aic icccived
by one, others by tuo 01 more of these means,
and that with equal or unequal frequency
Inoculation and absorption being closely allied,
a poison ccitainly inoculablc is piobably capable
of absorption by an unbroken mucous surface
1 Inoculation — The contagia of tables (as
hydrophobia), glanders, anthrax, and vaccinia,
the e \tra-coipoieal contagia of tetanus, ery-
sipelas, and scptic.emia , and the mtra-corporeal
leprosy are usually thus received, while an
abrasion gieatly facilitates the infection of
syphilis, chancre, and gonorrhoea Under excep-
tional circumstances others may be inoculated,
as smallpox, diphtheria, and tuberculosis
2 Absorption by mucous surfaces is the rule
with venereal diseases and with puerpeial septic-
aemia. Ophthalmia is the infection of the
conjunctiva with the purulent discharge from
other cases, in glanders and diphtheria the
microbes are arrested on tho nasal, pharyngeal,
or laiyngeal mucous surfaces, and the bronchi
rarely involved, except secondarily by extension.
Diphtheria, measles, scarlatina, etc, are easily
absorbed from infected pocket - handkeichiefs
and like articles
3. Inhalation is, however, the most frequent
means of communication of all the non-recurrent
mtra-corporeal contagia, viz variola and vari-
cella, typhus and plague, measles and rubella
(rotheln), v\ hooping-cough and mumps, as well
as of yellow and i elapsing fevei and some
others, also of tuberculosis ot the lungs and
cervical glands, contagious pneumonia, epidemic
cerebio-spmal meningitis, influcn/a, and diph-
theria Enteric fever IK, though rarely, and
choleia may possibly be, thus received, and it
has hitherto been univei sally believed that
malanal teveis aie conveyed aenally, though
mosquitoes aie no\v held to be the pnncipal
means
4 Ingestwn is ceituinly the rule with enteiic
fever, choleia, dysenteiy, and some forms of
diairhu'a, \\atei 01 ioods specifically contami-
nated being the cause of epidemic outbreaks,
and eating \\ith hands soiled \vith foxes, of the
personal communication of the disease The
milk of tubeiculous cows is the chief cause
of infantile tubei culosis, intestinal, memngeal,
\ertebral, etc Koot-and-mouth disease of cows
is communicated to man by then milk Scar-
latina, enteiic fevei, and diphtheiia may also be
coin eyed by milk as A vehicle, theic being no
bcttci cult me fluid foi most bactciia Lastly,
the imperfectly cooked flesh of tubeiculous
animals may be a means of infection
3 fnt>6ctt> — Flics play a more impoitant
pait in conveying infection than is commonly
supposed They cariy infective matter on
their feet and hunks from the sick to the sound
and to ai tides of food, while quite leccntly a
mass of evidence has been accumulating to
prove that mosquitoes, i e gnats, of certain
species, are tho actual vehicles of malarial
poisoning, the plasm<xlia or h.jematozoa of these
fevcis s\v aiming in the fluids of their bodies,
and being inoculated by then bites into the
human blood Dogs and cats may convey
infection in then coats, us human beings in
their clothes, but cats aie themselves susceptible
of diphtheiia, v\hich they ma} thus communicate
direct from one child to anothei
(B) Way\ of Eyrtis — All pathogenic microbes
leave the bodies of the sick by one or more
ways, the chief of \\hich aie (a) the mucus
secreted by the respiratoiy passages, throat,
and mouth, (ft) the intestinal evacuations;
(c) the urine , and (</) the seious and purulent
contents of vesicles and pustiftes, and possibly
detached epithelium The fiist- named is
specially important in relation to scarlet fever
and measles, and is probably the main source
of tho infection which not infrequently occurs
406
DISINFECTION
during convalescence of a case Too exclusne
attention has been attached to "desquama-
tion " as the principal cause, to the neglect of
the mucous membrane involved in the eaily
and latest stages oi the disease The " breath "
of patients suffeiing fiom infectious diseases is
by some considered to be a means of infection,
but the oudence foi this is not conclusive1
These points are of gieut practical importance
m connection with the science and practice of
disinfection
Streptococci are present in large numbers in
the urine of scarlatinal pitients, but attempts
to obtain cultivations from the cast-off epi-
thelium have been so unsuccessful as to cast
doubts on the universal belief in then mfectivity,
but Di ("lass of Chic.igo states that he has
grown from the mucus of the throat and the
epithelium alike a diplococcus perfectly chaiac-
teristic, and doubtlessly specific Ho explains
previous failures by the fact that the only
media in which it will grow are glycerine agar
with 5 pen cent of ttniliwl gat Jen Hotly and
milk
(C) Periods of Incubation and Infectn'enesv —
A knowledge of the incubation or period that
elapses between the meption of the infection
and the first manifestation of the s^ mptoms of
the disease, and of that during which the con-
valescent letains the power of romnmimating
the infection to otheis, is necessaiy to the
successful piactirc of disinfection and prophy-
laxis, especially in schools
Incubation- The statement of these penods
in our text-books is far fiom satisf actoi y, for
they aie, I tali wo, moie constant than is
generally supposed An erior on the side of
excessive caution is ceitamly safe, but if \\c
admit such wide langes as two to fifteen days,
or one to tmoc weeks, we depme ouisehes of
the means of tiacing am <ase to its soince
Dejeitwl Inftrtion — Many alleged instances
of extraoidmarilj piolonged infection aie really
cases of went exposuie to infected articles, but
it is also highly probable that one may cany
the contagion foi some days or a week on one's
clothes or peixon, i existing infection foi that
time For this Di Kemcke has suggested the
term "defeired infection," and such appaicnt
prolongation of the incubation peiiod is pcihaps
not infrequent
Intubation periods should be reckoned from
the moment of infection to that of the invasion
or commencement of the febule disturbance,
not to the appearance of the eruption, which is
a later stage in the course of some diseases, not
having anything conesponding to it m others
The incubation is propeily the period during
which their is* wo sensible evidence of disease
Among the difficulties and sources of error
in determining the duration of incubation aie
(1) the unceitainty attaching to the date of
exposuie alike when (a) no other cases are
known to exist in the noighbouihood , and (A)
when, as dining epidemics, opportunities of
infection are everywhere present , (2) the possi-
bility of deferred infection , or (3) of later
infection by fomites , (4) the insidious course of
some diseases, as enteric fevei and diphtheria in
their earlier stages , and (5) the fact that cases
infected successively fiom the same source may
be mistaken foi pumaty and secondary cases
with a \ery short interval bet \veen them
Perhaps the follow ing statement of the true
penods may bo taken as the nearest approach
to accinacy —
Short Incubationi
1-2 days
Kiysipelas
Septicoimia
Influen/a
Diphthena
Scarlatina
1-2 „
1-3
1-4
2-5
Lony Incubations
Measles 10-12 days
Smallpox 10-15 „
Variable Pet ?orfs
Cholera . 1-1 dajs
Whooping-cough 7-10 01 12 „
Typhus 7-14 01 16 „
En tci ic fever 12-20 „
Mumps 14-21 01 24 „
Vaiuella and rubella aie oi casionall} some-
what shoitei than smallpox and measles ic-
spectively The eniption follows the imasion
aftei one to two days in scailatina, two to
thiec in smallpox and tjphus, and thiee to fi\e
in measles
In a leccnt epidemic of nibella at Konmsbeig,
Dr. Thcodoi and othei medical men met a
number of cases of the ncuiience of the disease
in the same mdiudual aitei mtei\als of two to
six weeks
Quaiantine — A scholai who has been exposed
to infection during the holidays should not be
admitted, oi, if in sdiool, should be isolated foi
a period somewhat longer than the maximum
incubation peiiod, being meanwhile deemed a
"suspect," and not allowed to associate with
any susceptible mdi\idu.ils This should be,
in—
Scarlatina, 8 civ) s
Diphthena . 12 ,|
Measles . 16 „
Smallpox . . 18 „
Whooping-cough 21 ,,
Mumps 24 „
Varicella and rubella as smallpox and meaxles
Isolation — Dwation oflnfectiwty - -One who
has suffered from an infectious disease should,
after the most thoiough disinfection of his
person and clothes, be isolated from association
with susceptible peisons foi the following
penods
DISINFECTION
407
Scarlatina — Eight or ton weeks from the
appearance of the rash, desquamation having
ceased, and so long aftei that as the throat is
not perfectly healthy, 01 there IB an} discharge
fiom the none or eats
Measles anil Ruhella — Three weeks fiom
invasion, provided all cough, etc , ha\e ceased
Mumps — Four weeks, all spelling having
disappeared
Wkoopiruj-coiwjh — Six weeks from the recog-
nition of the cough, if it hd\e entirely lost its
spasmodic character, 01 iour if all cough what-
ever have ceased
Diphtheria — Four, or perhaps in very
mild cases three weeks, provided there he no
albummuiia or dischaigc from nose 01 ear, the
patient be piactically well, and the tin oat
appear perfectly healthy
A bacteriological examination of the pharyngeal
mucus should be made on se\eral consecutive
days, foi the bacilli may lemain for some time
virulent towards othei peisons, though inert
to\\aids the bcarei
Smallpojr — When all scabs have iallen and
the scais h,i\e healed
In the case of tin* last two we haxe it in our
power to piotect susceptible persons fiom infec-
tion, vix vaccination or t examination against
smallpox , and piophylaetic injections of anti-
toxin against diphthena, the iimiiiiiiit) confened
by these la>»t persisting foi about a month
The caihest c ommeucemeut of infottmtx. is «i
question of some practical impoitance, especi-
ally m the suppiession of epidemics in schools
There is no e\ ulence of the commumeabihtv of
uiij .uute specifics duiinu, the pinely uuubatne
pdiod, x\hilp as vet theie .110 no objective
symptoms, but it piobably begins with the very
euihest manifestation All susceptible persons
who hnxe associated with the sick, on 01 sub-
sequent to the hrst day of the imasion, should
be suspects and put in quaiantme, though when
the disease is one with a long incubation, the
isolation need not be enforced until the week
following exposure The infectn ity is, how c\ ei ,
but feeble, and prompt sepaiation is, as a rule,
successful, except with measles, m which infec-
tion mostly takes place before its nature is
suspected The evacuations of enteric fever
and of cholera are mfectixe \vhcn only a slight
looseness is obscixed
II DISINFECTION AND
Disinfection — (Joneial practical disinfecting
piocesscs are diiected to— (1) the destruction
of all microbes deposited with the dust on all
surfaces and projections, and m crevices and
recesses on or in the x\alls, floois, ceilings,
furniture, etc, of looms, 01 adhering to or con-
tained m furmtuie, cai pets, curtains, decorations,
etc, of rooms, as veil as clothing and other
domestic articles, (2) the destruction of the
mfectivity of excreta and expectoration, (3)
preventing the spread of infection by persons ,
and (4) destroying in iitu such microbes as,
though pathogenic, have also an extra-corporeal
or saprophytic existence
The re i no sal of offensive odouis and the pre-
vention of putrefaction have a certain and
occasional value, but theie can be no greater
error than the popukr confusion of deodorants,
and even of antiseptics, with disinfectants —
that is to say, with geinncides — although some
bodies partake of the propeities of more than
one of these gioups.
Deodorants that simply oxerpower an ill odour
by substituting an agreeable one are worse than
useless, those only having any real xaluo that
bicak up off ensue and injurious volatile bodies,
as hydiogcn or ammonium sulphides, and com-
bining with some or all of their molecules, fix
them in inert and inodorous compounds, and
those xxhich, giving oft' nascent oxygen to
organic mutter in a state of incipient decom-
position 01 unstable equilibrium, oxidise it with
such rapidity that the pioeess has been aptly
termed " wet combustion " These are repre-
sented icspcctnely by the actions of chlorine,
and of permanganate of potash and peroxide of
hydiogen The lattei, being mere oxidiscis,
ha\e little action on living bacteria They
have been hilly discussed m the article " Anti-
septic Tieatmcnt of Wounds" in vol i p 299
Disinfectants, m the restmted sense that the
word has now acquncd, aic yermicides, te
bodies capable of killing bacteria, and, m
practice, such only as do so tffectuaUy and per-
manently , for one that does not, fails altogether
to fulfil its purpose
Then absolute1 and relative values must be
learnt by laboratoiy experiments conducted on
strict scientihi methods, but in applying the
conclusions thus aimed at to actual practice
one must tike account of the different ( onditions
undei wlndi they aie employed, and of the
disturbing factois which, lightly excluded from
the laboiatoi}, haxc to be icckoucd with else-
x\heie
It is not enough to know that a substance is
a geinncide , one must know and must use it
m the icquisite quantities and degice of con-
ccntiation , nay inoie, one must make sine that
it comes into actual contact with the whole of
the bacteria Very few indeed of so-called
disinfections fulfil all these conditions, and if
they fail in one, they aie but illusions and
shams, little if at all better than the perfunctory
fumigation of tiavcllcis and their luggage that
until leceutly satisfied the officials in some
countnes Thus the 1 Ib of sulphur, or 11
cubic feet of sulphmous acid gas per 1000
cubic feet of space, now piewiibed for the dis-
infection of rooms, is based on Koch's observa-
tion that an atmosphere containing 1 per cent
of the gas was fatal to all bacteria in thirty
minutes, though not to their spores
408
DISINFECTION
But Koch recognised the difference between
his empty air-tight box and a furnished room
with leakage by doors and windows, and showed
that oven in his experimental chamber similar
cultures covered by a cloth or in a few folds of
filtering paper were protected from the action
of the gas.
Again, medical men \\}\o clearly appreciate
tho uses and action of sublimate solutions of
1 in 1000 or in 2000 respectively, are found
advising the addition of indefinite quantities of
the reagent to still more indefinite volumes
of excreta or sewage, by dilution with which
the proportion of tho sublimate \vould be in-
stantly reduced to anything between 1 in 10,000
and in infinity , whereas the quantity of the
reagent to be used should be calculated on the
liquid to be disinfected, as by adding 2 oz of a
1 per cent solution to a pint, or 16 02. to a
gallon of the excreta, if a strength of 1 in 1000
is desired.
Even then the fluid mixture should be
agitated, and, if thick, bo diluted before treat-
ment, for the dense coagula formed by the
action of the sublimate on albuminoid mattci
may otherwise enclose and protect the bacteria,
so that disinfection is incomplete.
The insufficiency of sulphur fumigations as
commonly pei formed may be demonstrated by
placing one silver coin on a table and anothei
in the pocket of a coat during the process,
when the former mill bo found blackened and
tho latter scarcely tarnished
Heat as a Dmnifectant — Heat is the most
certain means of disinfection Our exact know-
ledge of its efficacy dates fiom the investigations
of Koch, Wolfhugel, (Jaffky, and Loeifler in
1881, whoso conclusions were that —
(1) Non-sponfeious bactcua cannot survive
1J hour's exposure to hot air at 100° 0 , (2)
spores of moulds aic not killed by H hour's
exposure to hot air at 110°-115° C , (3) spores
of bacilli aie killed only alter 3 hours in hot an
at 140° C
They experimented on the Jl rtn*/t/«w, but
those of tubciculosis, according to Bonhoff and
Forster, die in 1 hour at 60" C , in 5 minutes
at 90° C , and in 1 minute at 100° C
But few fabrics, if any, can stand long ex-
posure to such tempcratuics in dry air without
serious damage, and several hours are rcqun ed
for the heat to penetrate tho interior of mat-
tresses 01 bales of goods. Moist heat is, however,
far more effectual, and does not injure the
majority of fabrics, leather being tho most im-
portant exception , while exposure to saturated
steam at 100° C for 15 minutes suffices to kill
even such resistant organisms as the B anthran*
and its spoics. Whether steam is more energetic
at high pressures, as 20 Ibs to the square inch,
than at lower pressure is, though probable, not
determined , but its power of penetration is
undoubtedly greater, and consequently a shorter
exposure is necessary, and there is less con-
densation of moisture on the articles submitted
to it An incidental advantage is found in the
fact that where steam powei is employed for
other purposes it is always worked at high
pressure, and may be utilised for the disinfect-
ing apparatus, though the initial cost of the
stronger chamber icquired will be greater
The penetration of the steam may be accelerated
by intermittent raising and lowering of the
pressure, the steam being let off, and aftei some
minutes turned on again The removal of the
moistuic of condensation is facilitated by pro-
ducing a partial vacuum, and then admitting
dry hot air at atmospheric pressure. The ex-
haustion is best effected by passing a jet of
steam across the mouth of a pipe communicat-
ing with the chamber until the gauge indicates
a " vacuum " of 20 inches, when air is admitted
at atmosphetic pressuie by a pipe surrounded
by a steam coil that taises its tcmpciature to
105° C , and the creation of «i " vacuum " pre-
viously to the admission of the steam is, as
regards its penetration, equivalent to raising its
pressure, and permits of equally rapid disin-
fection at loiiei temperatuics, \\ith consequent
less iisk of injury to the goods, a temperatuie
of 105" C being uudei these circumstances as
effective as one of 120° C would be otherwise
Washington Lyon's apparatus is peihaps the
best, as it is the most costly Heck's fixed and
poi table arc excellent, and much lews expensive ;
and Thresh's and Defiles' " Equifex " have each
featuies to recommend them.
Chemical Disinfectant* — Innumciablo moi-
ganic and oiganic bodies possess more 01 less of
germiudal properties, and numbers of these,
alone or in combination, ha\e been put on the
market as propnetary preparations, but too
often of unknown and very unceitam composi
tion, some being good, though their value be
exaggeiated, uhile others are feeble almost to
inertness
Chemical disinfectants may be considered
undei the seveial heads of (1) oxidiseis, bodies
giving off oxygen in the nascent or atomic state,
and theiefoic veiy actne, (2) halogens, 01
bodies evolving chlorine, bromine, or iodine in
the nascent state , (3) oxides of nitrogen , (4)
caustic alkalies, (5) acids, (6) metallic salts,
(7) the phenols and their derivatives , and (8)
foimic aldehyd
(1 ) Ozone and hydrogen peroxide are unstable
combinations, easily breaking up and setting
free oxygen in tho atomic state, thus Od = 02 + O
and Hjj02 = H2O + 0, but they are too expensive
for practical use.
In " sauitas," however, prepared by passing
air through oils of turpentine, camphor, etc,
floated on water, there is much H202 and some
0) formed in the slow oxidation of the "essential"
oils , and potassium permanganate, m the pres-
ence of acids or of organic matter, especially
DISINFECTION
409
if in a atate of incipient decomposition, gives
off " nascent " oxygen freely The latter, com-
monly known as "Condy's fluid," is largely
used for washing foul wounds, removing the
smell from the hands or from vessels that have
been in contact with putrid or f.ecal matteis,
and for sweetening meat that is slightly "tinned "
or game already too "high" It IN, howevei,
but a feeble germicide in solutions of less than B
per cent, and unless very dilute, it stains fabucs
a deep brown Samtas in 2 per cent solutions
may be used for the same purposes, and is free
horn these defects, being non-poisonous, colour-
less, and non-nritant It makes an elegant
toilet preparation, and is a fanly active oxidisci
(2) Ifalwjew* — C/tlot nte prcpaied by the
action of stiong acids on bleaching powdei or on
common salt and manganese dioxide is m the
jnewnce of water a powerful indirect oxidisei,
through its affinity for hydrogen It fhes
ammonia and breaks up hydrogen and am-
monium sulphides, as well .is the phosphorus
compounds e\olved in putiefac turn But it is
an uncertain bactencide
Ifypochfarow acid, HVC13O, is moie actne
than chlonno itself, and is o\olvod from " bleach-
ing powdei" ((ommonly but mcoiicctly called
" chloride of lime "), an impure calcium hypo-
chlonte, when acted on by acids, ex en though
slowly, by the CO^ in the an On contact with
moisture it splits up into IKJ1 and atomic
oxygen Bleaching powdei must theiefoie be
kept dry and not long before use It is neaily
valueless as a disinfectant or gcimicide, but
\eiy useful for destioying the biid smells fiom
gullies, dung-pits, pmies, and dust-bins aftei
they fame been emptied The icsidual (.ilcmin
chlonde being deliquescent, it cannot be sul)-
stitutcd for caustic lime foi washing walls
fodmet though a feeble oxidisei , is a strongei
germicide than c'hloime, and is used by some
suigeons foi disinfecting their hands, but its
cost alone, apart from other objections, excludes
it fiom general sanitary practice
(3) The onde* ofmtiogrn may in like manner
be rejected as unstable, expensive, and othei-
w me unsuitable
(4) Cawtic allahe* destioj bactena by dis-
solving their substance as well as the albuminoid
matters m which they may be embedded, but
weak alkaline solutions favoui the growth of
most Fresh burnt lime is thus a most effective
disinfectant in the form of lime wish (not white
wash, which is made with fine chalk) as an
application to walls Dry quicklime is caustic
and dehydrating
(5) Acids, if concentrated, are of course strong
bactericides, though not available in practice
But some bacilli, as that of cholera, arc* unable
to resist very moderate degrees of acidity, as
that present in a healthy stomach, or produced
by the use of sulphuric or other mineral acid
"lemonades," which are valuable preventives
during an epidemic Xufyhinoux acui stands on
its own merits It IN a better germicide than
chlorine or hypochlorous acid, and is still the
"oflfici.il disinfectant," sh.ii ing the honour with
carbolic acid and sublimate It is produced by
burning ciude sulphui 01 carbonic sulphide,
but since the foimei is hard to keep alight, and
the lattei dangeiously mflampuble, they aie
fast being superseded by the' use of the com-
pressed gas in cylmdeis It is a reducing
agent, decomposes sulphides, converts ammonia,
compound ammonias, and organic bases into
sulphites, and bleaches vegetable colouis
Sulphur dioxide (S02) is nritant and nrespn-
ablc, r) pei rent haung pioved fatal, though
0 5 per cent can be boine for some time. It
is soluble 111 water to the extent of 50 vols ,
but the solution is unstable
In the anhydrous state it is inert, acting as
a germicide only in the presence of moistuie ,
fumigations of rooms arc theicfore useless unless
the walls and everything to be disinfected be
first sprayed 01 wotted throughout, when its
bleaching action on all vegetable colouis would
be resented In Germany it has been thoioughly
discredited, but it holds its ground uiulei othcial
patronage in the United Kingdom, Fiance,
Sweden, Austiia, and the I mted States of
Amenca, wheie, however, the authmities re-
qune 4 pei cent instead of the 1 75 pei cent
that satisfies ouis The only piomment sani-
tanan on the Continent who ic tains any con-
fidence in it is Vallm of Tans , and its continued
sanction by 0111 Local (io\ eminent Board can
be accounted foi only by the absence of a body
of state officials engaged in original lescarch
like those of the K K (fecund Ami at Beihu,
the medical ofhccis ot oui Loeal Go\ eminent
Board being all hard-woiked inspectors 01 "chief
clerks "
Siilphwic acid might nuclei some- ciuum-
stanccs be employed with arhantage foi disin-
fecting heces 01 cesspits, since Stut/er found
005 pei cent in watci 01 sewage quickly fatal
to the bacilli of cholcia It would be especially
useful foi cleansing the bilges of vessels arriving
fiom infected ports or having had cases of choleia
on boaid duiuig the passage
Boric acid is a non-niit.int antiseptic in
suigical piactuc, and too much used as a food
picseivative, but has no claim to be considered
a disinfectant
(6) Metallic ti«lt\ Though feirous sulphate
at one time enjoyed a high icputatiou, the only
metallic salts calling foi notice aie those of zinc
and mercury
Zinc chloude is a powerful antiseptic in
solutions of 0 5 to 1 per cent, and a disinfectant
in 2 to 5 pei cent foi all but the most resistant
bactena None of these solutions iiijinc metals
01 fabiics " Sn W Burnett's Fluid " contains
50 to 70 pei cent, and the French "Eau dc
St Luc" about 75 per cent, but the vanable
408
DISINFECTION
But Koch recognised tho difference between
his empty air-tight box and a furnished room
with leakage by doors and windows, and showed
that even in his o\peiimental chamber similar
cultures covered by A cloth or in a few folds of
filtering paper were protected from the action
of the gas.
Again, medical men A\ho clearly appicciate
the uses and action of sublimate solutions of
1 m 1000 01 m 2000 respectively, arc found
advising the addition of indefinite quantities of
the reagent to still more indefinite volumes
of excreta or sewage, by dilution with which
the proportion of the sublimate \vould be in-
stantly icduced to anything between 1 in 10,000
and in infinity , whereas the quantity of the
reagent to be used should be calculated on the
liquid to be disinfected, as by adding 2 oz of a
1 per cent solution to a pint, or 16 oz to a
gallon of the excreta, if a stiength of 1 in 1000
is desired.
Even then the fluid mixtme should be
agitated, and, if thick, bo diluted before treat-
ment, for the dense coagula formed by the
action of the sublimate on albuminoid matter
may otherwise enclose and protect the bacteria,
so that disinfection is incomplete
Tho insufficiency of sulphur fumigations as
commonly performed may be demonstrated by
placing one silver com on a table and anothci
m the pocket of a coat during the process,
when the former A\ill be found blackened and
tho latter scarcely taimshcd
Heat as a Disinfectant — Heat is the most
certain means of disinfection Our exact know-
ledge of its efficacy dates from the investigations
of Koch, Wolfhugel, (Jaftky, and LoeihVr in
1881, whose conclusions ^\cro thut —
(1) Non-sponferous bacteria cannot survive
1J hour's exposure to hot an at 100" C , (2)
spores of moulds die not killed by U hour's
exposure to hot air at 110°-115° C , (3) spores
of bacilli are killed only after 3 horns in hot an
at 140° C
They experimented on the R anifaact8t\mt
those of tubeiculosis, according to Ronhofi and
Forster, die in 1 houi at 60" C , in 5 minutes
at 90° C , and m 1 minute at 100° C
But few fabrics, if any, can stand long ex-
posure to such tompciaturcs in dry air without
serious damage, and several hours are requn cd
for the heat to penetrate the interior of mat-
ti esses or bales of goods Moist heat is, however,
far more effectual, and does not injure tho
majority of fabrics, leather being the most im-
portant exception , while exposure to saturated
steam at 100° C. for 15 minutes suffices to kill
oven such resistant organisms as the B anthraas
and its spores. Whether steam is more energetic
at high pressures, as 20 Ibs to the square inch,
than at lower pressure is, though probable, not
determined , but its powei of penetration is
undoubtedly greater, and consequently a shorter
exposure is necessary, and there is less con-
densation of moisture on the articles submitted
to it. An incidental advantage is found in the
fact that where steam power is employed for
other purposes it is always worked at high
pressure, and may be utilised for the disinfect-
ing apparatus, though tho initial cost of the
stronger chamber required will be greater.
The penetration of the steam may be accelerated
by intermittent raising and lowering of the
pressure, the steam being let oft; and after some
minutes turned on again. The lemoval of the
moistuic of condensation is facilitated by pio-
ducmg a paitial vacuum, and then admitting
dry hot air at atmospheric pressure. The ex-
haustion is best effected by passing a jot of
steam across the mouth of a pipe communicat-
ing with the chamber until the gauge indicates
a " vacuum M of 20 inches, when air is admitted
at atmospheric picssiue by a pipe sunounded
by a steam coil that raises its tcmpeiature to
105° C , and the cieation of a "vacuum" pre-
viously to the admission of the steam is, as
regards its penetration, equivalent to raising its
piessurc, and permits of equally rapid disin-
fection at lovtei temperatures, \\ith consequent
less nsk of mjuiy to the goods, a temperature
of 10f)1 C. being undei these cncumstanccs as
effective as one of 120° C would be otherwise
Washington Lyon's appaiatus is perhaps the
best, as it is the most costly Reek's fixed and
portable arc excellent, and much less expensive ,
and Thresh's and Defiles' " Kqmfex " have each
features to recommend them
Chemical Disinfectant* — Inn umci able inor-
ganic and organic bodies possess more or less of
geimuidal properties, and numbcis of these,
alone or in combination, ha\e been put on the
maikct as propnetary prepaiations, but too
often of unknown and very unccitam composi-
tion, some being good, though their value be
exaggerated, \\hilc otheis are feeble almost to
inertness
Chemical disinfectants may be considered
under the several heads of (1) oxidiscis, bodies
giving off oxygen in the nascent or atomic state,
and therefore veiy active , (2) halogens, or
bodies evolving chlonne, biomme, or iodine in
the nascent state , (3) oxides of nitrogen , (4)
caustic alkalies, (5) acids, (6) metallic salts,
(7) the phenols and their derivatives , and (8)
formic aldehyd
(1) Ozone and hydrogen peroxide are unstable
combinations, easily bi caking up and sotting
free oxygen in the atomic state, thus 03 = 02 + O
and H202 = H20 + O, but they are too expensive
for practical use.
In " samtas," however, prepared by passing
air through oils of turpentine, camphor, etc ,
floated on water, there is much H202 and some
0, formed in the slow oxidation of the "essential"
oils , and potassium permanganate, in the pres-
ence of acids or of organic matter, especially
DISINFECTION
409
if in a state of incipient decomposition, gives
off " nascent " oxygon freely The latter, com-
monly known as "Condy's fluid," is largely
used for washing fonl wounds, removing the
smell from the hands or from vessels that ha>e
been m contact with putrid or f ducal rnatteis,
and for sweetening meat that is slightly "turned "
or game already too "high." It IK, howevei,
but a feeble germicide in solutions of less than 5
per cent, and unless very dilute, it stains fabrics
A deep brown Sanitas m 2 per cent solutions
may bo used for the same purposes, and is free
fiom these defects, being non-poisonous, colour-
less, and non-irntant. It makes an elegant
toilet preparation, and is a fanly active oxidiser
(2) Halogen* — Chltnme prepared by the
action of stiong acids on bleaching powder 01 on
common salt and manganese dioxide is in the
pteience of water a powerful indirect oxidisci,
through its affinity for hydiogcn It fixes
ammonia and bleaks up hydrogen and am-
monium sulphides, as well as the phosphorus
compounds evolved m putrefaction Hut it is
an uncertain bactericide
Hypnchlorfnu acid, H,2Cl/>, is moie acti\e
than chlorine itself, and is o\olvcd from " bleach-
ing powder" (commonly but incoiiectly tailed
" chloride of lime "), an impure calcium hypo-
chlonte, when acted on b\ acids, PA en though
slowly, by the CO2 in the an On contact with
moisture it splits up into IKJl and atomic
oxygen Bleaching powder must theiefoie be
kept dry and not long before use It is ncaily
valueless as a disinfectant or gozinicide, but
% cry useful for destroying the bad smells from
gullies, dung-pits, privies, and dust-bins ajtn
they have heen emptied The icsidual calcium
(hlonde being deliquescent, it cannot be sul>-
stituted foi caustu bmo foi washing walls
Iodine, though a feeble oxidiser, is a strongoi
"Cinncide than ihloiinc, and is used by some
suigcons for disinfecting their hands, but its
cost alone, apart from other objections excludes
it fiom geneial samtaiy practice
(3) The oudrs of nthogen may m hkomannei
be rejected as unstable, expensive, and othci-
w ise unsuitable
(4) Cawtic alkahc* destio) bactena by dis-
solving their substance as well as the albuminoid
matteis m which they may be embedded, but
weak alkaline solutions favoui the growth oi
most Fresh buint lime is thus a most effective
disinfectant in the form of him jws/t (not white
wash, which is made with fine chalk) as an
application to walls Dry quicklime is caustic
and dehydrating
(5) Acids, if concentrated, are of course strong
bactencidcs, though not available m practice
But some bacilli, as that of cholera, are unable
to resist very moderate degiees of acidity, as
that present in a healthy stomach, or produced
by the use of sulphuric or other mmeial acid
"lemonades," which are valuable pioventives
during an epidemic Huljthmmui acid stands on
its own merits It is a better germicide than
chlorine or hypochlorous acid, and is still the
"official disinfectant," shaimg the honour with
carbolic ucid and sublimate It is produced by
binning nude bulphiu oi carbonic sulphide,
but since the foimer is hard to keep alight, and
the lattei dangciously inflammable, they aie
fast being superseded by the use of the com-
pressed gas in cyhndeis. It is a reducing
agent, decomposes sulphides, conveits ammonia,
compound ammonias, and oiganic bases into
sulphites, and bleaches vegetable colour*
Sulphiu dioxide (S02) is nritant and irrespn-
able, "5 pci cent having proved fatal, though
0 5 per cent can be borne for some time It
is soluble in water to the extent of 50 vols ,
but the solution is unstable
In the anh}dicms state it is inert, acting as
a geinncide only in the presence of moistuic ,
fumigations of looms aie theieforc useless unless
the walls and everything to be disinfected be
first sprayed en wetted throughout, when its
bleaching action on .ill vegetable colouis would
be resented In Germany it has been thoioughly
disci edited, but it holds its giound undei ofhcul
patronage m the United Kingdom, Fiance,
Sweden, Austna, and the I uited Mates of
Amenca, wheie, howe\ei, the nuthontics re-
quiic i pei cent instead of the 17") pci cent
that satisfies ouis The only pi eminent sam-
taiian on the Continent who letams any con-
fidence in it is Vallm of Pans , and its continued
sanction by out Local (Jo\ eminent Board can
bo accounted foi onlj by the absence of a body
of state officials engaged in oiigiiul lescaich
like those of the1 A' A' (fciund Amt at Realm,
the medical oihceis oi oui Local (« en eminent
Boaul being .ill hard-worked mspcctoisoi "chief
clerks "
Sulphwu aad might nuclei some cncum-
stances be employed with advantage foi disin-
fecting f.eces 01 cesspits, since Stut/ei found
005 per cent m water 01 sewage quickly fatal
to the bac illi of choleia It would be especially
useful foi cleansing the bilges of vessels ai rump,
fiom infected poits or having had cases of choleia
mi board cluung the p«issage
/lone acttl is a non-initant antiseptic in
smgical piactue, and too much used as a food
pieseivative, hut has no claim to be considered
a disinfectant
(6) Metallic tidt* - -Though feirous sulphate
nt one time enjoyed a high leputation, the only
metallic salts calling foi notice aie those of zinc
and meicury
Zinc c/dotidf is a powerful antiseptic in
solutions of 0 5 to 1 per cent, and a disinfectant
in 2 to 5 pei cent foi all but the most resistant
bactcim None of these solutions injure metals
01 fabucs " Sn W Burnett's Fluid " contains
50 to 70 per cent, and the French "Eau de
St. Luc" about 75 pei cent, but the vanable
410
DISINFECTION
strength of these piopnetaiy preparations is
a great defect.
Mercuric Salt*— The cyanide and biniodule
are now piefeiied in suigciy, but the bichloiido
HggClj, common]} called conosive sublimate
or simply sublimate, stands unn vailed as the
universal disinfectant foi its eneigy, general
applicability, and cheapness Its poisonous
character is often mged against it, but the
dangei is far loss than is commonly supposed,
the smallest fatal dose being 3 to 5 giains, or
J to J pint of the 1 in 1000 solution, which
is the stiongest used Such a quantity could
not be drunk by accident, and the ounce that
might be sw.illowed in mistake would lepicscnt
L grain only, tiie \voist effect of which would
a little gastro-intcstmal disturbance , whereas
the same quantity of Burnett's Fluid, or a half
or even a quarter of an ounce of caibohc acid,
would very probably prove fatal Still, if people
are afraid to have it in a house, it might bo
coloured blue with indigo or laundry blue, when
it could not be mistaken for any medicine or
beverage
One part m 10,000 or 1 m 5000 is fatal to
all but the most resistant bacteria, and 1 in
1000 suthces to kill in a lew minutes even those
of unthi ax in watei, and all others u\eu in thick
fluids 01 iccccs To obtain this pioportion a
stock solution of 1 pci cent may be kept , with
10 pel cent of common salt or 0 1 per cent
of hjdrochloiic acid added to pi event dcteiioia-
tion through the deposit of a basic < hlonde
(7) Phenol, ChH/OH) —Commonly called cai-
bohc acid, it is rather of the uatuic of an alcohol
or hydroxjl derivative of a hydiocaibon radical
It is stiongly antiseptic, but neither poweifnl
nor certain as a disinfectant, for unless concen-
trated and allowed to act foi several dajs it
does little more than delay the geimmation
of spores Koch found that 1 per cent destroyed
the bacilli and 5 per cent the spoies of ant hi ax
m two days, but home bacilli aie even nion
resistant, and those of typhoid fevoi flourish
in a medium caibohsed to 1 pci cent
Carbolic powdcis consist of phenol incoi-
poiatcd with melt mmeial mattei, its minute
subdivision faumnnsj its volatilisation, a doubt-
ful advantage since aeual disinfection is an
illusion They should be guaranteed to contain
15 pei cent of phenol, though few do, and some
ahow only a tiace
The ciudo acid of the shops is in some ic-
spects superior to the pmc
Gietol 01 methyl phenol with its del natives
foims the chief constituent of lysol, cicolin, izal,
" J eyes' Fluid," and a host of similar nnxtuics
and preparations It is a better disinfectant
than phenol, ai&l some of its pioducts and
derivatives are much less poisonous
(8) Formaldehyd, COH H , Pat aformaldehyd,
C803H, H , — Polymcis of the aldehyd of methyl,
tho first being a pungent gas, very soluble in
water, from which it is given off again on heat-
ing, and the second a white ciystallme solid,
breaking up when heated into the normal alde-
hyd It is a very poweiful antiseptic, lecently
much used for pieservmg milk, fish, etc, and
a very good disinfectant In 1 pei cent solu-
tions it kills all miciobcs in from fifteen minutes
to one hour, and not being caustic 01 iintant,
and not fommig an insoluble compound with
soap, as sublimate and 7inc salts do, it may be
used without hesitation foi disinfecting the
hands, clothing, blushes, etc, and in laundry
woik It has a decided action on bactena CNCII
as a dry gas, though far less than when in solu-
tion or when the aiticlcs have been wetted
The so-called " Formalin " IM a 40 per cent solu-
tion of formaldchyd, and paiafoimaldehyd is sold
in tabloids, to be volatilised m a special lamp,
the " Alformant " When this is used the walls
and fuimtuie should bo picviously spiayed with
water It may be desctibed as tlie dome^tu,
as sublimate is, 01 should be, the official dis-
infectant
Disinfecting soaps and candles aic not to
be commended, being too teoble to be oi tin}
leal use, while gmug a false sense of scumt}
III — PKAClHMIj DlSIMM'lION
Pirparntaty M V'*«ms — The difficulties of dis-
infection, the nsk of spoiling things in the pio-
cess, and the necessity of destioymg such as
cannot be thoiougbly disinfected would be
minimised if the moment an infectious disease
is iccogmsed, or e\cn suspected, all taipets,
woollen cui tains, stuffed fumitme, fcathei beds,
down quilts, ,uid rugs were removed from the
loom, as well as clothing in chests of diaweis,
waidrobes, or hanging closets, «ind no fuimtuie
letamed beyond a table uud cane 01 wooden
chaiis, washing-stand, and the like The easy
American 01 Indian chairs, into the coiisti uc turn
ot which no textile fabnc except a little cam as
enteis, should be substituted for the aim-chans
01 couches usually provided foi the attendants
The oldest and the least valuable blankets and
bedding should be brought into icquisilion, 01,
bettci still, the oidmaiy matt i ess and flock 01
han bed be exchanged toi one stuffed with the
cheap but comfortable ssostcia or sca-wiack, com-
monly though incorrectly called "alva," which
may afterwards he burnt, the ticks being boiled
for future use As at this eaily stage infection
can scaiccly have taken place, it will be sufficient
to expose tho articles removed to the wind and
light in tho garden or yard
A loom on the highest floor, if lofty and
spacious with ample windows, is to bo preferred,
but on the next below, if tho topmost rooms
be in the roof with low ceilings, dormer windows,
and the like , tho door should be kept closed
and the window more or less open , and if tho
weathei permit, a fire, however small, kept
burning , if not, the chimney at any rate should
DISINFECTION
411
never be closed All windows on the staircase
should he open day arid night, and the doors
and windows of othci bedrooms during the day,
as should the dooi into the garden, if any, and
the front dooi also if kept on the chain
Special CoHKtdtnttioiw — These anticipatory
precautions may with advantage be taken m
all cases of known or suspected infectious
disease, but when its charactei is detei mined
the subsequent steps foi preventing the spread
of the infection will be icgulated as to both
their nature and the stringency \\ith which
they shall be entoiced by the cncumstances ot
the case
The medical man will have to take into
account (1) the picscuce of susceptible persons,
especially \vith regard to the age-incidence, and
fatality of the disease, (2) its degree of com-
mumcabihty to susceptible persons and the
dangei to lift* mvohed, (3) the persistence
or vitality of the miciobes and their spores out
of the body, (4) the "ways and means" of
infection
Thus (1) all persons who luuo not previously
passed thiough an attack of scarlatina aie
susceptible, but the susceptibility and fatality
is HO fai gieatei m childhood that adults o\ei
20 or 30 yeai s of ige need not bo taken much
cu fount of, and those past middle life may be
looked on as insusceptible ('2) Measles is the
most m lections of .ill diseases (except smallpox
in an um ace mated community), but the dangei
to life, except in infancy, is practically ml,
while the fatality of diphthena at all ages is
gicater than that of almost any othei (3) The
infection ot measles is evanescent, while those
ot scailatma and oi diphthena aie persistent
to an exttfioulin.il y degiee (I) Entenc fever
is spiead almost e\clusi\cly by the ftvun and
mine, which, g.iunng access to watei -supplies
o\en aftei peicolatmg many yaids thiough the
eaith, may infect an entire community , though
in a spacious and well-oideied suk-ioom the
danger to the attendants and household is in-
significant On the other hand, the infection
of scatlatma, diphthciia, 01 smallpov is with
oidmaiy caie easily conlmcd to the house,
though within it susceptible pel sons aie with
difficulty kept fioni contiactmg it But, jut
canton, no one need be susceptible, at least aftei
the first few days, to smallpov 01 diphthena,
foi in icvac ci nation we have the means of con-
feinng immunity for many years, and piophy-
lactic inoculation with chphtheiitic antitoMii
piotects fiom infection for about a month,
measuies that should never be omitted on the
appearance of cithei disease in a house
Economy of Sirl-room — During the course
of the illness all linen \\hen soiled or changed
should be immediately immersed in a solution
of "formalin," 1 part to 20 of water, or sub-
limate 1 in 2000, or zinc chloride 1 in 25, m
a glazed earthonwaie pan, such as u used for
keeping bread, and as soon as comeuicnt they
should be plunged for a quarter of an horn
m a copper ot boiling water Before applying
soap to the clothes it will be necessaiy to rinse
and wring them out in clean water if sublimate
or the zinc salt ha\e been used, since these,
especially the latter, foim insoluble compounds
with the fatty acids With c; formalin," which
does not in the least interfere with the lathei,
this precaution is not needed, and a wooden
or gahamsed tub may be used Cups, plates,
spoons, forks, etc , for the use of the patient
should be kept and washed in the loom, and
on no account sent downstairs
All f filiations should be immediately well
stiried with a 1 pel cent solution of sublimate
m the pioportion of 2 o/ to the pint before
being passed into the sewei 01 buried in the
earth, unless icseived for the inspection of the
medical attendants in the open air, not in a
closet or in a loom The mine is at ha*t as
infcc tive as the ficces
The Attendant* — Persons in attendance on
a patient suffciing fiom .smallpox, diphthcu.i,
01 scailatina, and, oi couise, typhus — though
this is not likely to be met with in pmatc
ptactice — should v avoid all contact with sus-
ceptible individuals, especially chilcheu It this
be impractu able, as when the circumstances
of the family pieducle the engagement of
piofessional muses, and the wife or mothei
must tike hei tutu with the patient and the
other childicn, she should, as indeed should
all muses, weai only cotton di esses, and these
changed twice a week at the least, while one
that has been soiled by the excreta in entenc
tever, 01 by the nasal and oial discharges in
diphtheria 01 scarlatina, should be at once
consigned to the disinfecting tub She should
have anothei chess hanging on the landing to
put on in the house, leaving that she had been
wearing behind in the loom
She must keep hei nails short, and aftei
dipping hei hands in the foi malm solution
(1 in L'O), cleanse them with hot water and
soap, using the nail-brush, befoic attending to
the othci c inldie.il
It would be most desn able that he? hail should
be cut bhoi* enough to be hequently washed, but
if not it should be enclosed in a cotton cap while*
in the loom, or a bathing- cap would be still
bettei
Conwth'ttentv —After smallpox and scailatnia,
so soon as ice oveiy has well ad\anc cd, the person
of the patient should be diMiifci ted by frequent
baths with hot watei and soap, the han cut short
and the head washed with formalin followed by
soap and water, soft soap being preferable to
hard The throat in scailatJha and diphtheria
should bo spiayed with a weak solution of Liq
sod chlorinate or formalin or Liq pot perm
daily foi seveial weeks, or so long as there is
any icdnoss, spelling, or iclaxation The use
412
DISINFECTION
of a spray and not a gaigle is to be lecom-
mended. Dr. danger's colour experiments prove
conclusively that a gargle does not come in
contact with the walls of tho pharynx or the
tonsils, and can act on the soft palate and aich
of the fauces only
When convalescence is complete, and tho
danger of infection considered past, it is advisable
that the patient, before tcturmug to his family,
should, especially if he have been in a hospital
or in a room with other patients, be sent away
for a week or tui o where he may breathe a pure
air and eliminate the lust traces of infection
Attendants who, though insusceptible to
scarlatina, 01 not having contracted diphtheria,
are sensible of some degree of sore tin oat, indicat-
ing resisted and aboitrve infection, should use
the spray to their throats and past* a week 01 so
in a pure air, as much as possible out of doois,
in the same manner, to rid themselves of the
germs w hich, though they have had little effect
on them, may communicate the disease to others
moic susceptible
Social Consideration* — As with tho pie cau-
tions to bo taken to pi event the spread of infec-
tion during the illness of the patient, so with the
subsequent disinfection of the room, bedding,
etc, a certain latitude may be allowed accord-
ing to the natuie of the disease With measles
and whooping-cough, tho miciobes of which
polish veiy soon, a thorough cleaning oi the
toom, washing of linen, blankets, etc, and ex-
posure of beds, pillows, and unwashable curtains,
carpets, etc , such as is familiar to housekeepers
.is a "spring cleaning," suffices With cutenc
fever no more is needed except foi bedding and
linen that have been in contact with the patient ,
but beds and mattresses should bo destroyed
lathei than disinfected, since they are suie to
be more or less saturated with the fluid and
mostly involuntary evacuations oi the patient
In puei petal fever, a septic disease, the contagion
of which maintains an extia-corpoieal existence,
and is most pcisistcut, the destruction of the
bedding is imperative, for the neglect of this
precaution may cause the death of a parturient
woman occupying the bed even after the lapse
of a year 01 longer
In diphtheria, scarlatina, and smallpox it is
highly advisable to substitute for pocket hand-
kei chiefs pieces of soft cotton or linen tags,
which should be burnt us often as used, or the
Japanese paper handkerchiefs if they aie to
be had
After Death — Infection does not cease with
death The number of w ell - authenticated
instances of tho propagation, sometimes wide-
spread, of smallpox, diphtheria, scarlatina,
typhus, etc , throVigh contact, direct or indirect,
with the bodies of persons dying of those diseases
is so great thai much more stringent legislation
would bo a public benefit At any rate, the
body should, so soon as possible, be put into the
coffin, bedded in some disinfecting absorbent,
the best being probably Hartmarm's sublimated
wood-wool, or, in rougher practice, sublimated
sawdust, "formalin" might be spiaycd over
all Tho coffin should be placed m an empty
room, covered with its lid, though so soon as
tho first signs of cadaveric change appear it
should bo screwed down, and burial (or crema-
tion) follow at tho earliest possible date. There
is no excuse for "last looks," and to allow a
"last kiss" is morally criminal When an
empty room is not available, oi foi other reasons
the medical attendant deems the retention of
the corpse a d.inger to the health oi the inmates
of a house, he can obtain an older fiom a
magistrate foi its removal to the mortuary,
and its burial from thence , and it is much to
be desired that public mortuaries were largely
and voluntarily used foi the deposit of corpses
between death and burial, irrespective of social
position, of accommodation, or the natuie oi
the disease
The practice m Munich and the arrangements
of tho magnificent mortuary of that city, wheie
rich and poor alike "lie in state" mid surround-
ings suggestive rather of a sacied edifice than of
the dead -house and post-mortem loom, well
deserve study and imitation It beais no le-
semblance to that "chamber of hoirors" the
Moigue at Pans, the purpose of which, to
preserve unclaimed bodies as long as possible,
is entirely different.
Disinfection o/ Room, et( — The common
method of aerial disinfection by means of
sulphur m very inadequate Whatovoi efficacy
it appeals to ha^kC is doubtless due to the
thorough and prolonged milux of fresh an which
follows its use The object of disinfection is to
kill the germs adhering to the walls and floors,
accumulating m the dust deposited on ledges,
cornices, and furniture, and lodging rn the folds
oi \voollen fabrics and the stuffing of bedding,
chairs, etc , just the places where they arc least
accessible to gaseous agents.
The fust step is to have all wash<ible fabrics
plunged in boiling \\ater for a quarter of .in
horn or twenty minutes, and mattresses, beds,
bolsters, pillows, and, if such have unfortunately
been left m the loom, all quilts, carpets, rugs,
and the stuffing oi easy-chaus, packed up for
transmission to tho disinfecting station Next,
the floor should be well washed, in fact swilled,
with 1 in 1000 sublimate solution, care being
taken to saturate the interspaces between the
boards, and the walls spiayed with the same by
means of a garden syringe or othei apparatus, or
simply washed down with a cloth or mop The
ledges over the door and window frames and the
wood-work of the sashes should be washed \vith
a cloth dipped in tho solution, and the furniture
treated m the same way The ceiling should
then be limcwashed, special care being paid to
ornamental cornices, roses, and other decorative
DISINFECTION
413
\vork, that no part shall escape the application
The loom should then be left with the windows
open for a day 01 two, after which the coiling
may be whitewashed 01 papered, the walls, if
papered, stripped and repapered , and the floor
scrubbed with soup and soda, which will convert
any remaining sublimate into a non-volatile and
insoluble compound A fresh coat of paint to
doors and windows would be a fuither security
Fenders, fiie-nons, and metal \vork geneially,
which would be spoiled by the sublimate, need
only be well polished. •
Wheie a piopci steam disinfecting oven is !
available, all beds, carpets, and such-like should
be sent theie, 01 if there be none available the
ticking and cases must be boiled , good hair or
feathois may be steeped in a 1 in 1000 sublimate
solution foi half an houi and then \\ashcd in
pure vvatei, but flock 01 cheap hau and mixed
stuffings .ue fai better burnt
Legislation - -The vaiious enactments bearing
on the pi event ion and repression of infectious
diseases will be icfeiied to m the aiticles INFEC-
TION , QUARANTINE, etc
Dislocation. — The scpaiation 01 dis-
placement oi bones (more especially) from their
natmal relation** to each other It may be j
complete (the ends of the bones o\ei lapping) 01
incomplete (partial) , simple (no othei iivjtuy),
oi complicated (one 01 both bones fiactured), oi
compound (wound making the joint communicate
\\ith the extenoi) , habitual 01 iclapsing (le-
cunent) , spontaneous (not due to violence), oi
tiaumatic (due to violence) Hee ANKffc-JoiNr,
REGION oi, INTURIFS (Dislocation of Pttonnil
Tew I on •», Ti 1 i o- Tar sn I and Comjtountl Di tlot at ion s,
(indDisfocationofA *tntyaltu) , BR ACHIAL PLI-AL s,
SUROICAI AHFrrioNs'or, CHKSI, iNiuiuts or
(Dislocation of Jttbs) , DEronvnriEs (Congenital
Dislocations) , ELHOW- JOINT, LNJUHILN \NH
DISEASES o* (Dtdocatt/Mv) , FIM.ERS (Injutift,
Dislocations) , HnvJoiNT, INMLHIKS OF (Disloca-
tions), KMiE-Joixr, INJURIES 01 (Dislocations),
LENS, CRYSTALLINE (Diydateuient) , Mnum,
INJURIES AND DISEASES or IMF .!A\\ (Dislocation
of Lowei Jaw), NERVES, PERIPHERAL (Disloca-
tion of Ulnar No ve) , SHOULDER, DISEASES AM>
IVJIRIES oi (Dislocations of Humnns, AcionuaJ
Etui of dhii'tcle, amf JJneps Tcwfan) , SPINE,
SURGICAL AtthCLioMi oi (Fractute- Dislocation) ,
STERNO-CLAMCULAR JOINT (Injmits), WRIS-J-
JOINT, INJURIES (Dislocations)
DlSOmata. — Double monsteis 01 united
twins, in contrast to the mono&omatous tciata
or single monsters (Tantffi) See TFRATOLOOY
Disorder, *SW DISEASE — Disorder is
generally legaided as a milder teim than disease,
and does not indicate structural alterations
Dlspar.— Unequal, unlike.
Dispensary. In the strict sense dispeu
sary means a place where medicines are made
up or dispensed , but it has come to mean also
an institution vvheie poor patients arc seen,
examined, prescubed for, and given medicines
and (sometimes) surgical appliances, gratis, 01 for
a nominal fee (Chanty 01 Public Dispensancs)
Dispensatory. —A non-ofticial Phaima-
copona, containing, in paiticulai, the phaima-
ceutical details lespecting dings
Dispensing:. -Making up 01 putting up
medic UK'S accotding to a prescribed formula
(i e a presci iption) The dispenser has to be
veiy caieful to lead the presci iptiou carefully
and thoughtfully, to be alert to detect incom-
patible^ oi wrong doses, to label the medicine
carefully (" Poison," "External Application only,"
"Shake the Bottle"), etc £e« PRESCKIUIXU
Displacement. — A dislocation, moie
especially of one 01 other oi the mtcinal oigans,
c y of the uteius, spleen, etc1
Disposal.— Disposal oi sewage, of refuse,
of the dead, etc See SM\ AGL AN i> DRAINAGE , etc
Disposition. — Constitution or diathesis
01 tendency
Dissection - Wounds. <sVe Posi-
MOHTBM MET HODS (Kulesof Pt vcedure, Posonal)
Disseminated.— Scattered or disciete,
as m disseminated s< leiosis Kee PARAIASIS
(Paralysis with Ttvmot ot Atacy, Dissenuivited
ticli i oiit>)
Dissociation.— The sepaiation and re-
cognition of the elements of a tissue or oigan
by histological methods (staining, teasing, etc )
Dissociation of personality means the bieakmg
up of the "Ego" into two 01 moie "sub-
conscious paitneis," as in Piofcssoi Pi mre's
patient, " Miss Bcauchamp "
Dissolution. — The bieakmg up of a
1 issue 01 of the anatomical elements oi a tissue ,
moibul softening oi a tissue , death , or the dis-
appeaiame of fill traces oi an embiyo which has
died m eail} antenatal life
Dissolution, Law of. -Drugs (e<j
alcohol) acting on the brain and spinal cold aic
subject to what has been called the Law of
Dissolution, "when a ding affects functions
progiessively, those fiist affected aie the highest
in development — that is to h,iv, they aio the last
acquired by the individual and the last to appear
in the species The next affected are those next
to highest, and so on , till fhftilly the lowest oi
all horn an c\olutionaiy point of view, that is
to say the functions of i expiration and circula-
tion, are affected" (Hale White) See ALKALOIDS
(Law of Dissolution)
414
DISTAL
Distal. — Distant or remote, opposed,
therefore, to proximal , the distal end of a long
bone is that farthest from the tiuuk Distad
means in tho direction of 01 towards tho distal
end of a bone 01 a limb, etc
Distemper. --An infectious catarihal
disease affe< ting caimvoious animals, especially
dogs, and consisting in inflammation of the
mucous membrane of the nose, thioat, eyes,
bronchi, and ahmoutaiy tract, the skin is
sometimes affected , it is most common in dogs
under one yeai of age and is very fatal (about
50 per cent) , it is a sort of " dog-measles,"
and one attack usually confeis immunity The
word distemper maj also be used of any
disease
Distich lasiS. -The pieseiiec of a second
row of eyelashes, occulting as a congenital
anomaly See KYELIDS, AvrircrioNh OF (Dn-
tithiasn
Distoma or Distomum.— The</*<-
tomtdce belong to the tiem.itodes or flukes
.imong the parasitu \vorms, there ate se\eial
species including (ti^tomitiu /tepatnmn (the liver
tiuke), distomum (nmfofattiHt (the smallei hvei
fluke), divtonui htfuuttoftttun (bilhai/ia h.uinato
bia), etc See LIVER (Luv> J'mavtm) , LUNGS,
P \RASITIC AFFECTIONS op (DistoHiitui Rinyei t) ,
PARASITES (Helminth*, Tt cnttittn{t!<)
Distort! US.— The teiatological state in
which there is a double mouth m double lo\\or
jaw (Hallantyno's Antenatal Patlwlogy, vol n
pp 3N9, 447)
Dlta Bark.— The diied bark of ALt<mia
vhohms, containing an alkaloid tlitaine
(C41H30NJO) having a paralysing effect on
motor nerve endings (in mammals), it is
oflicial in tho Indian and Colonial Addendum
(1900) to the British Phaimacopona of 1898
>SVe ALSTON I A
Dlttrlch'S PlUgS.— Yellowish plugs of
sputum, varying m srze fiom a millet seed to a
beau, formed m the bronchi in cases of gangrene
of the lung and bronchicctasis tiee BRONCHI,
BRONCHITIS (Clinical Varutte*, Fvtod Biowh-
Itlk) , EXPECTOR \TION (J''t»in)
DlureldeS. — Bodies consisting of two
unmodified or modified urea molecules, linked
together by an acid nucleus, eq tho purm
bodies , in birds and icptiles they are tho sub-
stances in which nitrogen is principally elimi-
nated , the most irnpoitant of them is unc acid,
and others are xanthin, hypoxanthm, and allan-
tom See LIVBR^ PHYSIOLOGY OP (Regulation of
Supply of Proteidv) , PHYSIOLOGY, EXCRBTTON
(Nitrogenous tiubitancev, Diureide*)
Diuresis. — Increased or abundant excre-
tion of urine, occurring as a sign of disease, as
the iesu.lt of taking some mediumes, or because
of altered physiological conditions, polyuna
See DIURETICS.
DluretlCS. See also ALCOHOL, BUCHU,
CALOMEL , CAFFEINE , DIGITALIS , DIURETIN ,
HEART, MYOCARDIUM AND ENDOCARDIUM (Treat-
ment, Sttoplumlhw and otlun Catdiac Jieniedies) ,
JUNIPER, POIAHU, SQUILL, etc, etc. — A
diutetic is usually defined as an agent which
increases the elimination of uime Such a
definition is a convenient clinical one, but \\e
must bcai in mind that in curtain diseases, e y
granulai contiacted kidney, tho failuie in
evcietion is one m the elimination of solids,
and not m the dischaige of watei, and in such
cases thcio are important indications in con-
nection with the daily intake of mtiogenous
ingiedients
Tho dillifulties that invest this subject either
from the pharmacological or clinical point of
view are consideiable They depend laigely on
the fact that very consideiable vanations in the
total excietion of mine ot nil not only m health,
but also in many diseases, — vanations which
aio appaiently quite independent of the dietetic
01 other tioatment in opeiation
Thus in health \\e find v.uialions occurring
quite independent of the imount of fluid m-
gested, and also indejx'iident of tho amount
lost by the various othei chaimels, these vaiia-
tions depending on the vai)iug activity of the
renal stiuetiucs
Tho mechanism of ien.il sen letion will be fully
discussed m tho article " Kidney", hero it will
suffice to give a gcneial outline of tho factors
\vhich are concerned m dmiesis, at the same
time indicating the diffeieut points that call foi
considoiation in seeking to estimate the potency
of an agent with supposed diuretic influence
As a pioof of the vet} maiked vaiiatious in
tho amount cxcietcd from day to day, quite
independently of tho employment of any agent
of supposed dim otic influence, tho following
figures may bo quoted —
Case I
June 8, 1 200 c c urine
„ 9,1352
„ 10, 1700
„ 11, 1305
» 12, 990
„ 13, 1645
Case TI
Oct 29, 1865 cc mine
„ 30, 1950
„ 31,2375
Nov 4, 2470
These are taken from the middle of a scries
of detailed observations on the mine of two
hospital patients under similar treatment from
day to day, and one can readily imagine from
DIURETICS
415
those figures that a powerful diuretic influence
might be attached to a drug employed at a
time when the renal secretion was low The
cause of these variations is unknown, but their
existence must be recognised when seeking to
define the dun otic action of any remedy in
use
There are many things which have to be
carefully considered in lonnection with the
subject of diuresis, and there aie many points
of difficulty in then consideration — points dc-
ixuidiug on oui want of at cm ate knowledge of
the agencies concerned in the icnal secretion in
health as well as disease
The foicf rtiiviru/ the I/fond thiough the kid-
neys has hist to be consideiod This has in
great moasuie to bo detei mined by the state ot
the general blood-pi essme as estimated by the
pulse Wo must, howevei, beai m mind that
theie may be mci eased vaso-motoi tone m the
kulnoj', of local orijrin, dependent u|x»n altera-
tions m the splanchnic area, awl it is interesting
in this connection to note the close lelationship
which has been shown In Hill to exist between
the splanchnic aica and the regulation of the
ccicbial emulation As an instance oi diuresis
lesulting horn general mcieased .11 tonal tension
we have the influence oi cold
Then the itnte of the Mood itself has to be
considcied It may bo th.it the ^nations m
the amount ot mine e\i ruled liom d ly to day in
some cases of gout aio lamely dependent on the
lolativo amount of toxic material picsent Apai t
fioni the picseiKCof toxic substances, excess oi
uric acid in the blood and the amount of salts
Tcqune considc i ation, and Null bo n foiled to
latei The lomlitwn ot the Inlmi/^ themsehes
is a fuithei point moiiting Aoiy caieful con-
sideiation On the one hand theie may be
some defect in the state of thn sec lotiug stiuc-
tuios in the nlomoiuli and the tubules, 01 some
obstiuction in the excieLoiy channels, 01, on
the othoi hind, the peimeabihty of the kicluoxs
may be impaned, 01 theie may bo mteifoieme
\\ith the venous cnculation While .ill thesu
lactois have to bo boino in mind, it is exceed-
ingly dithcult and fioquenUy impossible to
determine which of thorn has been at fault, 01,
in other woids, which of them has boon influ-
enced, and how, by the diuretic used in any
given case In disease we may find a gieatei
poimcability associated with diminished velocity,
and obstnu tion to the disc haige fiom the kidnev
Dnuosib may occui thiough an elevation of
the aitcual tension, through an excess of watoi,
or by an excess of salts
The ingostion of watoi piobably acts in a
complex manner the total bulk of the blood is
augmented, tissue metabolism is modified, with
lesultmg increased excietion of waste pi od nets,
and the icnal capillaiy pressure is taised An
excess of salts acts similarly, but in different
directions here fluid is withdrawn from the
cells, thus tending to increased total bulk of that
fluid , further, the osmotic pressure is increased,
and the general mctalwhsm as well as renal
metabolism influenced
It has been thought that one reason why
potassium salts are more powerful diuretics than
sodium salts depends on the fact that the former
are naturally less abundant iri the blood, and
are thucfore moie stimulating and active on
account ot their gi cater diffusive power
The action of alkaline and acid salts differs
somewhat from those of the ncutial , the formei
increase pioduction of uiea, which being a
stimulant to renal exciction piomotos diuresis
Acid salts tend to diminish urea pioduction, but
indiii e a flow ol alkaline fluid iron) the tissues,
and thus me lease the amount oi salts and water
m the blood with resulting dimosis.
The compounds of the xanthm group, notibly
caftc me, a< t by modifying icnal metabolism, and
by also stimulating tho uiculation
fntht fiffOH\ lor tltt n w of Di M? t ti< s — Diuretics
,ne so frequently indicated in \arious cardiac,
rospnatoiy, and ienal diseases, and also in many
conditions of general disoideied metabolism,
that only a fe\\ general statements need be
quoted
The first essential foi the clinician in all coses
is to ondoa\ our to gang'' the1 state of the kidney
itself and the ^tate ot the cardiovascular s\stem
This has to be done by a detailed goni-ral ex-
amination of the subjective and objective symp-
tom's piosont in each case
In till cases, 1110100% ei, it is advisable that the
functions of the auxiluiy excrotoiy oigans be
]udi< musty piomotcd The use oi a vegetable
puigativc pill, 01 calomel m pill foim, with an
occasional moming saline, and the use of hydro-
theiapeutic lemedies to pi omoto the skin func-
tion, aio \eiy inipoitant aids to tioatment
11, aitei consideration, the conclusion is
aimed .it, that the dolective societioii losults
fiom low v.isc ulai tension, digitalis, 01 a similarly
acting body, is the lomedy jmr tncllcnce A
pi osi upturn like the following can be com-
mended —
K Potass, eitiat gi xxx
Spn ehlcnoioimi ll\^xx
Tinet digitalis ll^x
Infus buohu 5s"5
])ose for an adult, t d s , to bo followed by
a copious dunk of watoi
Thc« foipgomj> illustiates how we may advan-
tageously combine dun otic s of difteient classes,
the digitalis acting niiiuly tluough the general
blood-pi essine, the potash and buchu acting on
tin* kidney Htruetuio, directly «uded, m the case
of potash, by altoi ations in geift>ral tissue meta-
bolism Citiato of potash 01 lithia alone, or m
combination with buchu or scopaiium as a
vehicle, may be mentioned as suitable drugs in
cases whore a vasculai dun otic is not indicated.
416
DIURETICS
The nitrites 111 huge doses are also serviceable
remedies, then exact mode of action being un-
known As previously mentioned, the dim otic
action of pl.un water either alone or follow-
ing the use of dnuetio drills cannot be too
strongly emphasised As a geneial rule it
should be taken on an empty stomach at sot
times, three 01 four times daily, in quantities
varying fioni one-half to one pint or more
Dlliretin.— A pioprietary diuretic medi-
cine, sahcylatc of theobiommo and sodium, it
is used in diopsj duo to heait and kidney
troubles, the dose is 5 to 15 giains
Divagation. — Rambling speech 01
thought, especially oi tho msano
Divalent. — Dtvahntui bivalent, as applied,
for example, to an acid, means "capable of le
placing two atoms of hydiogen in a compound "
Divergence. Me OCULAR MUSCLES,
AFFECTIONS OF (Paialyw)
Diver's Paralysis. St,e SPINE, SUROI-
CAL AFHtCTlONH OF (Gdi^On DlWl\r)
DB vert iCU I it iS.— Inflammation of Mec-
kel's diveiticulum
DivertiCUlum.— A side-btan<h of a
canal in cavity, especially one ending blindly ,
a ciil-de-sat Some divuitnuLi h.ue special
names, eg J/invtt/'f di\eituulum (a cul-de-sat
aiising fioin tlie ICTOCI paitof the ileuin), NucVs
divertuulum (canal of Niuk), duodenal divci-
ticulum (ampulla of Vatei), etc See IMKS-
IIVES, SUIKIHJAI. ArrEf'noNs OF (Intestinal Off
tttuittoii by M«kel\ divettttulu/ii) , (KsopiiAous
((£}<tnj>h<t</efil J'ouc/ie s) , PosT-Mommi MPTHODH
(Jiody-Cavttie<i, Abdomen, Divetltiuln)
DlVUlsiOn.— lUpid, foicible dilatation of
a canal 01 hollow oigan, such as the uicthia or
the cervix utcii
Dizziness. *v?e Vhuru^)
Dobie'S Line.— The dim line in the
middle of the deal baud of a muscular fibul
»SV Pii \hioixxiT, Tissue (Mu&de, Mtmtvte of)
Dochmius Duodenal is. *svc PARA
SITES (NeiiMtwle^ Unciuaiial)u(xleiialis,Ari)ii/lo-
stomii Duodenale)
Docimasia. — An examination or test
((Si 8oKt/xu^w, I piove), moio especially of hvc-
birth , the mvestig.ition of tho heait and lungs,
groat vessels, and stomach, etc , in older to
determine whether an infant has breathed after
bnth ,SVe M^piciNK, FouKNbic (Injanticule,
Hydrrntntic Teit)
See ANTHRAX (Lower Animnh,
Dogs and Catt>) , DISTEMPER, BICKETS (Mot but
Anatomy, Puppies)
DollchOCephaly. — The long - shaped
skull, that m which the anteio-postenor dia-
meter is relatively long as compaicd with the
tiansverse , with a cephalic index of lew* than
75 *SVe AMHROPOTX)OY.
DolichOCnemiC.— Long-legged (from
(!i 8oAix"s» ^°nK> an^ KVll'lM> *'10 P*1"* of the
leg between the knee and tho ankle), having
tho leg nearly as long as the thigh
DollchohierlC.— Having the sacrum
long m compaiison to its hieadth (fioni (h.
fioA.tx«»«, long, and te/oos, the sacicd bone).
DolichOpelllC. — Having the antero-
postoiioi (or conjugate) diameter oi the pehic
bum as long as or longer than the tiansveise
Dolor. — Pain 01 sufteimg Vanous quali-
fying adjectives may be added, such as dolot
mi* it>, slight pain , dtJtn atror, agonising pain ,
tlolot tapttts, headache , do/or dentiwn, toothache^
dolm colitu*, colicky pain, etc In the pluial
do/otes signifies pains, and especially the pains of
labom (dolotes ad JHU turn), which may be slight
at hist (doloiesjmffmratite^ d<>l(»t>\ />?« wyienft}*)
and vciy seveic in Uio later stage (ttolote\
cttnqrwtivtntr*), «md slight again aftei labour is
o\er (tlolweb pueijwaium ot after-pain1*) tiee
L \KOUII, STAGES AND DURATION
Domestic Measures.— Since domes-
tic measures \aiy so gieatly in rapaciU,
medidiies ought to be dispensed as fai as
possible in bottles with graduated markings on
the glass and tho direction " one-sixth oi one-
ts\ellUi three times a day," etc , but as a
gcncial iiilc tho teaspoon holds about one fluid
diachm, the dessert-spoon about two fluid
diachms, the tablespoon about half a fluid ounce,
the wine-glass about t\\o fluid ounces, the tea-
cup about live fluid ouiues, the breakfast-cup
about eight fluid ounces, and tho tumbler about
eleven fluid ounces The diop cannot be safel}
legaidcd as exactly equivalent to one minim
Domicile, Law Of. — The place or
countiy \vhcic a poison's peimanent home is , it
may difter fioni his place of icsidence, for he
may be living temporally, but not indefmitel} ,
in a foieign country, in cases of insanity, a
lunatic " usually retains the domicile which he
possessed at the time when he began to be
legally treated as non comjtos "
Donda Ndilffa. >SV SKIN DISEASES
OF mis TROPICS (Ttojncal P/uii/edvuna) — The
name means literally " brother " or " companion
ulcei "
Donovan - Leishman Bodies.—
Small oval bodies (paiasitic), pi obably protozoan
in nature, found in the spleen, liver, blood, etc ,
in cases of malana, chronic dysentery, kala-azar,
low fever, etc
DONOVAN'S SOLUTION
417
Donovan's Solution.— Liquor arscnu
et hydrargyn icdidi. See MERCURY
Dorema
AMMONIACUM
Ammonlacum.
See
. — A soporific or hypnotic medi-
cine, said to bo amylene chloial 01 dnnethylethyl-
carbmolchloral , it is a colourless lujmd with an
unpleasant taste , it is to be obtained in 50 pci
cent solution, and the dose is from 0*5 to 3 grams
(8 to 45 giams)
Dorsad. — Tovvaids the dorsal region
Dorsal Or Dorsal IS. See ANEURYSM
(Lower Limb, Dorsal Artery), ARTERIES, LIG\-
TURE OP (Dorsalis Pedi*) , BRACIIIAL PLEXUS,
SURGICAL AFHECTIONS OF (Doisal Nerve**) ,
LABOUR, DIAGNOSIS AND MBCHAMSM (Trait werve
Lien) , etc
DorSO». — In compound words doi so-
sigmfics relating to the back, e g dorso-lumbar,
etc The expies«sions tloi to-anterior and doito-
poi>tenot refor to the i elation of the back of the
foetus to the uterus of the mother
DorSOdynia. — Muscular rheumatism
affecting the upper pait of the back
Dosage. See PiuMJiuiiUW — A dov is the
quantity of a medicine to be taken at one time ,
a maximum or full dose is the laigcst quantity
which can bo safely taken, \\ hilo .in infinitesimal
dose is one so small as to be regarded as homojo-
pathic The study of doses is called Powloyy
Dotage. — Senile fceblc-mindedness
Dothienenteritis. - Typhoid fever
(from (ir fio0i//v, a small abscess, and errc/iny, a
piece of gut 01 intestine)
Double Consciousness.— A mor-
bid (somnambulistic) state in which there is
apparently u double personality in the same
individual , an oxtraoidinaiy ease is that of Miss
Beauchamp, reported by Profossoi Pi moe of
Boston (1906) See UINCOXSPIOUSNESH (DoMe
Consciouvie^) , CRIMINAL KmroNhiiiiiiTA , IN-
SANITY, NAIURB AND SYMPTOMS (Delusional,
Alternative Pei ymahty)
DOU ble Monsters. See TKRAT* .r oo Y ,
also LABOUR, FAULTS IN FHR PASSENGER (Double
Monster*)
Double Vision. See ALCOHOLISM
(Sensory Phenomena), OCULAR MUSCLES,
AFFECTIONS OP (Paralysis, Double Vivwn) , TARES
DORSALIS (Symptomatology, Ocular Para/ wit)
Doubt, Insanity Of.— Doubting mad-
ness (malmlie du <?<>ute or monomanie t aisonnante)
is that foim of mental disorder in which the
patient is morbidly scrupulous about the ob-
servance of minor details of accuracy in conduct
or abnormally timid in regard to the common
risks of everyday life See INSANITY, NAIUUE
AND SiMPTUiu (Insane Dejects of Inhibition,
Foulie de doute or Switheting Insanity)
Douche. — A jet or stream of watei,
simple or medicated, hot or cold, directed with
some force against the surface of the body or
into one of the canals opening- on the surface of
the body (eg the ear, nose, vagina, rectum,
etc ) , the name is also given to the instrument
used, and to the act of applying the water 01
lotion Air is occasionally used See ABORTION
(Treatment of Inevitable) , BALNEOIAMIY (Douche
Hath*, Ilypotfiermal, Thermal, and Subthamal
Donchei, Scott h Doucfte, etc), HYDROPAFHY
(Douches, Ascending, Descending, Spinal,
Scottish, Air, Underwater), LABOUR, MANAOE-
HENr or (Abepst*) , LABOUR, INJURIES (Inversion
of Utci its, Treatment) , Noun, CHRONIC IN-
FLAMMAIION (7'teatment, Nasal Douches) , PUER-
i-ERiUM, PHYSIOLOGY (Management, Douching) ,
FUFUPKRIUN, PATHOLOGY (Piuviwal Infection,
Prophylaxis and Treatment) , UTERUS, INFLAM-
MATION op (Chtomc Metntis)
Douglas, Mechanism of. — A
mode of spontaneous delivery, which occasionally
happens m the case of transverse presentations
of the ( hild left to nature , described first by
John C Douglas (Dublin, 1819), "spontaneous
evolution "
Douglas, Pouch Of.— The pouch of
pci itoneum lying in front of the rectum (in the
postenor pait of the pelvis) and behind the
bladder or the uterus (in the female subject) ,
desciibed by James Douglas (1675-1742), and
named aftei him
Dourlne. — A disease occurring in horses,
transmitted by coitus (hence the synonymous
teim "mal de coit"), duo to a trypanosome,
and in some respects resembling syphilis (angio-
neuiotie tudema, sclerosis of neivous system,
spontaneous fractuics, and dislocations) See
PARASIIES (Proto-oa, Tryjuanosomata, Ttypano-
t>o/tui of Dow ine)
Dover's Powder (Pulvls Ipeca-
cuanhas Com pOSlt US). — Contains
opium, ipecacuanha, and sulphate of potassium
See OPIUM , TOXICOLOGY (Opium and Moiphine)
"Dowsing" Method. See H*DRO-
PATin (Hot- Ait Application*)
DraCOntlaSlS. — (Jmnca-woim disease ,
the disease duo to the Fdarta or Dracunculua
Medinemi* See FILARIASIS (Fi lav la Afedinenms)
DraCOntiSOniUS.— A variety of gastro-
schisis, that teratological type m which there
is median eventratiou of thoiax and abdomen,
twisting of the vertebral column, and a pecubai
honzontal arrangement of the ribs (like the
wings of a dragon 01 flying lizard)
27
418
DEACUNCULUS
DraCU I1CU I MS. See FJLARIASIS (Ftlat w,
Mcdinensis).
Dragon's BlOOd.— A resin (crimson in
colour) found as an exudation from the fruit
of the Rattan palm (Calamus draro\ containing
dracoalban (C^H40O4), and draco? even (C2,,H44OJ)
Drainage. — The lenioval of superfluous
water and of sewage from lands and dwellings
(w SEWAGE AND DRAINAGE), suryical drainage
is the removal (by means of tubes or counter-
openings 01 posture) of fluids from wounds 01
cavities (natural or artificial) oi the body (sei
Awnr TREATMENT OF WOUNDS, Drainage ,
BLADDER, INJURIES AND DISEASES, Cystitii, Treat-
nient, Drainage, BLADDER, INJURIES AND DIS-
EASES, Tumour*, Drainage t MENINGI-US, TUBER-
CULOUS, DraiiKiye of Latetal Ventiicle*).
DrastlCS.— Medicines acting quickly and
violently, especially purgatives (y.v ), such AS
croton oil, jalap, cLitcnum, bcammony, podo-
phylluni, etc &e PHARMACOLOGY
Draught. #e«HAUhTus, PRESCRIBING
Dreams. Xee SLEEP, NORMAL AND MORBID
(Ilypnagoi/tc titate, />*mwis), HKARF, Mvo-
CAHDTUM AND ENDOCARDIUM (tiympfo/Hflfufot/y,
Cetebral tiymptom<t) , MIND, EDUCATION OF,
MORPHINOMANIA (Efiecti, Dreams)
Dressings.
»SVc a/so AsEPrtO TREAl'MKVr 01- WoUVDS,
B\Ni>\ciL,s , Fmsr AID
THE question of the most suitable dressing foi
rounds sustained accidentally and intentionally
inflicted received no final ansxver until a com-
paratively few yeais ago, when the principles and
details oi aseptic suigery were definitely elaboi-
ated Many factors conspired to achieve this
result, such as the invention of the mi< ioscope,and
the discovery of the goim theory, with its widely
ramifying and important results , but of all of
them, the work of Lord Lister is paramount
His conception, founded upon a true scientific
basis, and expanded on practical lines, which
lesulted in the employment of antiseptics, has
been the means of advancing the rational treat-
ment of wounds to its piescnt and apparently
final position, and the aseptic ticatmcnt of
wounds has followed so rapidly upon the anti-
septic treatment of wounds that thete are to be
found surgeons who tieat then wounds upon
the older lines, and text- books written but a
few yeais ago by representative surgeons enun-
ciate doctrines which to-day appear to be
heretical to the modem aseptic surgeon
In a practical work, a history of the endless
vanety of dressings which have been used from
the earliest times is out of place, but those
curious on this subject will find information in
almost any surgical work published prior to the
pre-Listenan era Day by day the rivalry
between different antiseptic dressings grows less
keen as the leal value of the aseptic dressing
is appreciated Accordingly, the subject of
suigical dicssmgu becomes icstricted to an
account of the methods of obtaining a sterilised
diessmg, and a description of those compara-
tively few conditions in which an antiseptic
dicssing is inoio suitable
With legaid to the dicssing of wounds which
are expected to inn an aseptic course and to
heal by first intention, there is still some diffei-
ence of opinion among surgeons The difference
lies in this, that one group of surgeons, feeling
incredulous as to the possibility of having the
skin aseptic in the ncighbomhood of a wound,
consider it necessaiy to apply to the wound an
antiseptic dressing, one which, on account of its
antiseptic propcitics, will pi event the develop-
ment of pyogcnic oigamsms in the vicinity of,
or actually in the wound , while the other gioup
of suigeons, relying upon then attempts to
rcndei the \Kinity of the wound and the wound
itself tiseptic, content themselxes with employ-
ing a dressing wlmh has meiely been sterilised
If this latter view is the concct one, then it of
necessity follows that the subject of surgical
dressings sis applied to wounds believed to be
asoptic and expected to heal by hist intention
becomes very much narrowed down It theie-
foio matteis veiy little what is the nature of
the diessmg, so long <us its chief i unction is
fulfilled, vix that of shutting off the wound
from the bacterial WOT Id until it is healed As
a matter of iact gan/o is the matciial almost
invariably selected, for, owing to its te\tuie, it
permits of easy sterilisation 1 1 is comfortable,
and readily absorbs any oo/mg from the wound
but any linen 01 cotton fabric is almost as
suitable
Those suigeons, 1 1 the laige majority of
surgeons, who advocate a simple sterilised
dicssing for a wound do so for the following
reasons —
1 As both the wound and the dressing are
aseptic, suppuration cannot occur in the wound
unless pyogcnic organisms are mtioduced fiom
without, and a dressing of almost any matciml,
if properly prepaicd and applied, will pi event
this
2. If pyogenic oigamsms have, during the
operation, been mtioduced into the wound, an
antiseptic dressing on the wound will have as
little effect as an aseptic dressing in preventing
then development
3 The we of an antiseptic in the drewng is
apt to Ite t el ted ft/ion, and to diminish the strin-
gency of the precautions which must be taken to
secure true asepsis
4 Its simplicity in preparation
The pieparation of the gauze, or other
material, can be efficiently and rapidly carried
out m hospital practice, more especially if the
operating room is piovided with a steam
stciiliser, in private practice aseptic gauze has
DRESSINGS
419
advantages ovci any antiseptic dressing, which
at the time of use may actually be septic, and
nothing is moie readily obtained in even the
smallest cottage than a pan of water in which
tlu» dressing may be boiled and sterilised in ten
minutes, and also, fiom the fact that their is no
antiseptic in the dicssing which may be relied
upon, it is piobablc that all the other piccau-
tions which aie Liken before an operation
to secure asepsis will be moic carefully and
thoioughly earned out It is well to apply to
the wound suvci.il layers of gauze, covered b\
absorbent wool sufficient in quantity to enable
equable piessure to be applied, to add to the
eomfoit of the patient by pi eventing irritation
ot chafing fiom the bandage, and to furthci
dimmish the usk of pyogcnic oigamsms fiom
\\ithout coming in contact with the wound
And, aftei all, it v\ ill happen in only exceptional
oases th.it infection of an accuiately closed
aseptic wound by pyogenic organisms fiom
without will pioduce moie than superfici.il
supp i nation in the wound
In the event of asepsis not being maintained
dining the healing of the wound the typi< il
symptoms will appeal — p.un and <h scorn Jolt m
the wound, and possibly a use of tcmpciatuic,
which will be an mduatum that the wound
icquiies to be chessed If Uie septic change is
due to a stitch abscess, removal of the offending
stitch and the application of an antiseptic diess-
mg may be sulliuent to pievent fuithei infection
<il the wound, this dicssmg sliould, so long as
theie is any trace of sepsis, be changed daiU
J<\>r this puipose double c-v.imde 01 carbolic
gauxe m.i} be used, and some smgeons put a
layei of .iseptu gutta-percha tissue or jaconet
over the wet gauze to furthei the absoiption of
pus fiom the wound If the septic mischief is
m the deepei paits of the wound se\eial stiUhes
should be lemovcd, the septic pait of the wound
swabbed with lodofojm gau/e, and a similai
diessing applied , so long as the wound lemains
septic, it should be swabbed daily with icxlofoim
gau/e, and a veij successful method of prevent-
ing the clischaigc accumulating in the wound is
to mtioduco into the wound a few stiands of
stenlised woistcd whuh may be impregnated
with aseptic lodofoim Mi Stiles of Kdmlmigh
has done much to populaiise the use ot woisted
m the tieatment of wounds lecjuning diamage
It may be mentioned heie that lodoioim is not
alvva}s aseptic, but its ascpticity may be
seemed by keeping it m a 1 in 1000 solution
of coirosive sublimate, no chemical change taking
place, and the vessel containing the uxlofoim
should, fiom tune to tune, be shaken up m
order that the uxlofoim and the corrosive
sublimate may be thoroughly mixed
In wounds which aie not expected to heal
by fiiwt intention, t e those wounds m which a
drainage-tube is necessary , those wounds in
which, as in emergency operations, there is some
doubt as to their complete ascpticity, those
wounds, such as those left after cuicttmg tor
lupus, m which the edges are not in contact,
those wounds winch cannot be with certainty
rendeicd aseptic befoie or dining the operation
— to such wounds it is .ichisablc to apply a
diessing which contains an antiseptic in siuh
quantity as to be effective without being
nutating, and for tin-, purpose the double
cjamde 01 caibolic gau/e may be used, 01,
better still, gau/e which has been fust stenlised
and then wiung out of an antiseptic lotion, such
ascaiholic acid 1 in 40, lysol 1 m 1 00, or bm iodide
of meicury 1 in 1000 (It is almost superfluous
to point out that an antiscptu diessing is dc-
pmcd of its antiseptic value if it is 'mpietniated
with an antiseptic befoie htciihsation , foi,
dui ing the pioccss, the volatile antiseptic is
diiven oft ) In such cases, it is well to change
the dicssum soon after the opeiation — on the
following day at latest — for the antiseptic diess-
mg becomes valueless .is such so soon as the
antiseptic volatilises It is a mistake to apply
l.uge quantities ot absoibent wool ovei a wound
foi the sake ot soaking up the discharge fiom
it, except in those cases, such as psois abscess
and cmpjicma, in which the dischaige is likely
to be veiy profuse , and the piactice of putting
a quantity e>f absoibent wool as a pad on a
diessing which shows sinus ot the dischaige
being "thioiifih" is to be dcpiecated, for, undei
sue h t neumstances, the dev elopmcnt and glow th
of pyogenic oiganisms is encouiaged
Summaiismg, then, it may be stated that in
the use of wounds behoved to be aseptic, in
which the suiiounding skin is deluded to be
aseptic, and which aie meant to heal by first
intention without the employment of a cb, image-
tube, and oven, also, m the case of septic wounds
which are believed to have been icndcicd aseptic'
dining the opeiation, the best diessing consists
of scveial layein of sterilised gauze, covcicd by
absorbent wool and ictamed in position by a
bandage In wounds in legions in which it is
no easy mattei to lendci the skin aseptic, and
whcie the dressings aie apt to be soiled — such
as the inguinal legion — and in wounds not
expected to heal without suppuiation, it is
advisable to apply a diessing of sevcial layers
of gau/e which have been first stenlised and
then dipped in one of the antiseptic lotions
alluded to above As manulactuieiH do not
supply antiseptic diessmgs whuh have- been
pieviouslv. stenlised except when specially
ordered to do so, and even then, as their
methods cannot be so ichable as those of a
surgeon 01 of a tiamcd assistant, it is to be
iccommcndcd that the prepaiation oi the gau/e
be caincd out undei the burf eon's immediate
observation
1 am indebted to Messrs J F Macfarlan
and Co of Edinburgh (m whose works Lord
Lister spent much tune when endeavouring to
420
DRESSINGS
produce a cheap and antiseptic dressing, und
who were the til at manufacturer* to place such
an article upon the market) ioi the follow ing
list of antiseptic di casings ariangcd in the order
m which they are demanded —
Gauzes
1. Double Cjanide
(Mercury and Zinc)
2. Carbolic
3 lodoform
4. Sal Alembroth
5 Sublimate
6 Bone
7 Salicylic
Absot bent Lint*
1 Doric
2 Carbolic
3 lodofoim
4. Sublimate
5 Sal Alembroth
6. Double Cyanide
Abwtbent Wools
1. Sublimate
2 Sal Alembroth
3 Salicylic
4 Bone
5 Carbolic
6 Double Cyanide
7 lodoform
Percpntagf
of ,
AlltiHHptU I
5
10-20
1
a
20
4
45
5
10
HO
.15
5
3
10
Though the same geneial pimciplcs underlie
the application of dressings to any part of the
body, whether for disease or injury, it occasion-
ally happens that some modification is necessary,
whether on account of the nature of the wound
or the part m which it occurs
1 Dicssings for injuries to and after opera-
tions on the eye require, owing to the sensitive-
ness of that structure, to be of a rion-iriitating
natiuc Weak lotions are used here, and the
antiseptic drobsings employed are those in which
the antiseptic is mild, such as boric lint or gauze,
01 those in \\hich the percentage of antiseptic is
low.
2 Dressings for the perineum and genital
organs should contain an antiseptic, owing to
the difficulty of securing asepsis of the parts,
and owing to the risk of infection of the wounds
by the faeces or urine.
3. For artificial anus and focal fistula car-
bohsed tow is the dressing in general use , it is
admirably absorbent, and the tar which it con-
tains » most efficient in concealing or disguising
the faecal odour
4 Dressings for wounds fiom which the dis-
charge is copious*— such as empycema and psoas
abscess — should bo abundant and antiseptic to
arrest, as far as possible, the development of
pyogcmc and other organisms
5. Dressings foi syphilitic sores should, m
addition to the employment of an antiseptic
dusting powder, such as lodoform or calamme,
be impregnated with a mercurial antiseptic, and
there is none bettei than corrosive sublimate.
Black mercurial lotion is also used extensively
for syphilitic sores
6 Dresbingb for various diseases of the skin
\\ill be described in detail in the proper place
There can be little doubt that antiseptic dress-
ings for those skin diseases in which pyogcmc
organisms are present ha\o scuicely received
that recognition from dermatologists which they
deserve It is unfortunate that the majonty
of chemists cannot be i el led upon to dispense
ointments the asepticity of which is undoubted ;
and, in those discs, rq the various forms of
eczema, more lapid healing might often result
if the ointment which might happen to contain
no antiseptic weie aseptic, but this can rarely
be the rase
CGI tain untowaid icsults occasionally follow
the injudicious employment of certain antiseptic
dressings, or the employment of antiseptic
dressings on certain individuals of pecuhai
idiosyncrasy Smnlai lesults sometimes occui
after the use of antiseptic lotions
Bone acid may pioducc a localised erythema ,
in exceptional <ases it has occasioned a wide-
spread erythema Its internal use is much
more likely to cause toxic sj mptoms
Carbolic acid should nevci be used in such
concentration as to have a local uritatmg effect ,
but as a lotion, and in the olden days w hen the
carbolic spray was in everyday use, it not in-
frequently piodueed severe local and general
symptoms, eq carboltina, which have pioved
fatal The hands of some are very susceptible
to carbolic acid as a lotion for instruments,
i enduring the skin haul and liable to crack, and
therefore hard to render aseptic.
Salicylic acid, as an antiseptic dressing foi
wounds, is even more uritatmg than carbolic
acid, and forms of ei uption may bo produced by
its use, even m small percentages (cry them atoua,
urticari.il, vesicular, peteclnal, etc )
Corrosive sublimate, when used in dressings,
may cause much irritation of the skin, and it IB.
not uncommon to find parts which have been
prepared for operation by the application of a
wet corrosive dressing covered with an erythe-
matous eruption in which many minute pustules
are present Some hands are peculmily sus-
ceptible to it, and its use by instrumental ewers
not mfioqucntly produces a painful condition of
the matrix of the finger-nails Corrosive sub-
limate cannot be too carefully used as a lotion
for douching wounds or mucous surfaces, for,
by its absorption, it readily produces toxic
symptoms
lodofoim may produce a rash of an erythe-
matous, vesicular, or bullous character , and the
idiosyncrasy of certain individuals is very marked
m the use of this antiseptic. Wounds which.
DRESSINGS
421
have been stuffed with .111 lodofonn dressing, or
cavities — such «IH tuberculous joints — which
have been filled with an lodoform emulsion,
occasionally result in the appearance of an
erysipelatous rash, which rapidly disappeais on
the withdrawal of the antiseptic , but there arc
on record many cases which have resulted in
death by the absorption of lodoioim
A not mmnpoitant aspect of suigical di easing
is that ot rendering first aid to the wounded
There are now many thousand men and women
in Great Britain who have leccived certificates
of proficiency from the St John's 01 the St
Andrew's Ambulance Association, and who con-
sider themsehes qualified (among other things)
to apply a tcmpoiary dressing to those who
have sustained wounds The lecLmeis of those
associations cannot be sufficiently impressed
with the impottancc of teaching their pupils
the \alue of mteifciing as little as possible with
wounds, and instead of washing them out, even
with an antiseptic lotion, of meiely covering
them with an aseptic diessing, howevci homely,
which can be lapidly and easily obtained
Von Beigmann found in the Kusso-Tmkish
war that in 18 selected cases of compound
comminuted fiactmc at the knee-joint, thorough
disinfection of the sui rounding skin, the appli-
cation of a salicylic gau/e dressing and a plastei
of Pans splint pio\cd sufficient foi It to heal
without suppuration.
Foi the temporary ticatmcnt of wounds on
the battlefield, it can scaieely be expected th.it
an aseptic diessmg will be at hand, and aimv
surgeons have usually to employ an .in ti septic
dressing, but it is dcsnable that those diessings
should be fiist sterilised
Drink Ing-Clip. <s'«> INVUID FJ-HMM,
(0 'en f ml Set viny of Font?)
Drinking- Water. See CONMIPATION
(Cawe*, Dnnluv/-Watti)9 THYROID GLAND,
MEDICAL ((Jottti', Etiolo'/?/) , Toxifouxn
(Plum/nun, />///// my -Watei) , Tii'iiom FEVER
(Etiology, Watet Supply)
Droitwlch. See BALVEOLOM ((heat
Britain, Afwtated), MINERAL WATERS (Munatn?
Xalme IVatett)
Dromotherapy.— Ticatment by iun-
nmg eveicises in the attitude of flexion ("la
course en flexion"), the aims aie flexed .»t the
•elbows and held well Kick, the head is slightly
elevated, and the spine kept stiaight, it is
leconmiended in cases of disease due to slowing
of nutrition and the troubles ansiug theiefiom,
and it forms a useful variety of respiratory
gymnastics in chronic disease of the lungs
{F Reguault)
DromotroplC.
FLUENCE
See BATHMOTROPIC IN-
Drop. See DOMESTIC MEASURES (J/u
Dropsy. See also ABDOMINAL
(Pressure - Symptom*) , ASCII FS , BERIBERI ,
DIABETES MELLITUS, DHOPM, EPIDEMIC ,
HEART, MYOCARDIUM AND ENDOCARDIUM (Effect*
or Cardiac Disease, Dropsy) , HEART, MYO-
CARDIUM AND ENDOCARDIUM (Symptomatolwiy%
Dtapiy) , LARDACLOUS DEUENFRATIOV (Effect*) ,
LUNT(., TUBERCULOSIS op (Complications, Integu-
menttny St/t>temt (Er/rma) , NEPHRITIS (Chnual
Feature*, Acute, Chtonic) , OVARIES, DISEASES
ov (Xyntptom* of Ovatian, Tumour), PRB«-
NA\rv (A/ectHtn of the Amman, ffydramnws) ,
SCARIET FLVEK (Uamj&uatum*, Diseases of the
UiiiMry System) — Diopsy is dcfc'ied as the
accumulation of fluid in the subcutaneous
tissue and serous < avities of the body.
Vai ions teims .tie applied to this condition as
met with 111 diffeient situations, eq ascites,
h>drothora\, hjdioccle, and liydrocephalus
The teims (vduma md an.isaica aie also em-
ployed, the formei induatmg local dropsy in
subcutaneous tissue, Lt lie lattei j» w idespread
general dropsy
Diopsy is a symptom, and is usually asso-
ciated eithei with prnnaiy taidio- vascular or
renal disease In both instances the diagnosis
of the ease can readily be amved at Although
occasionally thcie aie mixed cases, where the
cardi(M asculai lesions are secondaiy to renal
disease, cases aie occasionally seen with well-
maikcd diopsy of the lower extremities, appar-
ently of causeless oiigm One such case, a girl
of sixteen, has come undci the writer's observa-
tion Heic cardiac and renal diseases could be
excluded Snmlaily filaiiasis, and a careful
pelvic and othci examination revealed nothing
th.it might by piessure or othenvise produce
the disease The treatment of this wise was as
unsatisfactoiy as its natiue was doubtful The
significance and treatment of dropsy mill be
consideied in the aiticles dealing with the
"Heart" and "Nephritis," and the local
dropsies undoi their icspective headings
The only outstanding local diopsy meiitmg
special attention is ascites, and this is fully
considered in \ol i p 285
The object of the present aitide is to give a
gencial outline of the etiological factois at woik
m the pioduction of dropsy
Although much could be wntten on this
subject, we know coinpaiatively little of definite
pi actual importance Every clinician is familiar
\vith cases of ad\anccd caidio-vasculai disease
without dropsy, and of other cases less serious
in natuie whcie (vdema may be a prominent
featui e The same can be Haul of various forms
of kidney disease, and so fiir, there is no
adequate explanation f 01 thcommg foi these
anomaheb The question ically resolves itself
into the fundamental one of the primary factois
conceincd in the movement of lymph, and then
422
DROPSY
to a consideiation of the influence of various
diseased states on these different tactois On
neither of these points can final and complete
statements be made The physical and chemical
natures of the fluids aie discussed elsewhere
(See "Fluids, Examination oi Pathological ")
The agencies at work in promoting the
movement of lymph will he considered under
"Lymphatic System," and it will suffice to
indicate here the directions in which these
agencies may be modified
For convenience thcso will be stated cate-
gorically, but in nature no such arbitiary lino
can be drawn, as not one but many factois ate
frequently at work in any gueu Otiso
I. Cardio-vasculai Disoasc — Any condition
which induces cither increased for\\aid (aitenal)
pleasure, 01 an increased backward (venous)
pressure, especially the latter, piedisposes to
the occuireucc1 ot diopsj In both c«isos the
pnmaiy causo is piobablj a vital alteiatum in
the capillary endothehum, and in both, physical
causes the results of piessuie aio also at woik
Expciiments have sho\vn that obstiuctiou to
the \enous return in a limb c\en %\hen com-
plete is not sufficient to induce diopsy, as the
lymphatic system possesses a lemaiLiblo com-
pensatory powci
If the increased venous pressure is associated
with an increased afflux of arteiial bluod, such
as might arise* from vaso-motoi distuibance, the
tendency to dropsy is much increased
Jn all such cases the influence of any associ-
ated .tlteicd quality of the blood, whether due
to a simple hydnemu, piesence of salts in
excess, lendormg diffusion more easx, or the
presence ot \atious toxic bodies, lias to bo
carefully considered
A wateiy state ot the blood .done has been
shown by experiment to be nisuthcicnt to pio-
duce diopsy until the hydiaMiuc condition has
Listed .1 suthuent time to alter the xitahty of
the endothehum Vaiious other experiments
h.uo been made by physiologists on the ettocts
of the injection of glucose and other bodies into
the blood-sticMiu, and the icsults go fai to
indicate the nnpoitant part played by alteied
states of the blood
II Lymphatic System — With rogaid to the
lymphatic system experimental obsei\ itions
have shown that obstiuction to a lymphatic
trunk is not in itself sufhcicnt to induce diopsy il
tho othei parts of the vascular system «uc intact
III. Nervous Sjstem — The influence* of the
nervous system is undoubted, but tho exact
modo of action is uncertain We know that
there aic at least two directions in which the
neivous system may act («) Tluough altera-
tion of the vjfeo-motor mechanism imohed,
(/>) in virtue of the trophic influence on the
tissues Of those two the latter, although more
indeterminate, is probably tho moie important,
and it is to difforem cs in the vital absorboiit power
of the tissues that \\o must mainly look in oxplana-
ation of the occurrence of dropsy in many cases
Local drvpsitR have, as a iiile, local causes,
but apart from the influence ot gravity and the
picsence of .1 definable obstruction of a \ossel,
as by a thrombus, in every case it is advisable
to think of, tenatim, the nature of the arteiial
afflux (of the local pulse), the heedoin of the
xenons return, the absoibent power of the
tissues, especially the endothehum and the
general neuro-musculai tone of tho individual
DHHJUOSI* — While tho recognition of dropsy
is easy, great difficulty is frequently expeiienccd
in appoitioiung due significance to the un-
poitaut causal agents in any gneu case It is
impoiUut to iccognise this with a xievk to
accurate prognosis and successful treatment
Gieat icgard should bo paid to the state oi
general blood-pi essuio, and the \\oikmg pouer
of the light and loft hcait should be separately
imestigatcd The existence of toxic bodies in
the blood may frequently be inf cried fiom the
quantity and quality of the urine voided, coi-
roboiatixe cMdcnce being obtained from a study
ot the caso as a wholo, and especially the state
of the (ontial UOMOUS SA stein
/'/wjrwosw. — This depends outnely upon the
cause and upon amenability to treatment A
consideiatiou of the various points rcfened to
undor diagnosis me of fiist impoitance
Treatment — Tho fust indication is to tost tho
cause, and if dependent on any specific toxic
lK)dy, €f/ bonbon, tho ticatmcnt appropriate to
that disease must bo adopted Otherwise the
tioatmcnt must be conducted ou the gcneial
lines indicated by the diagnosis
Completo icbt in >>cd, ludicious rise of band-
ages, and tho use of \anoiis caidiac tonics, and
cai ef ul attention to the functions of the skin,
bowels, and kidnoAs, aic the lomodios ot
liieatcst SOIMCO An ouaMoual saline is the
best foim of purgativo ft is also advisable
to limit the amount ot fluid ingested, and in
severe cases boneht is obtained by aspiration
(qi>) or by the use of Southoy's tubes, can*
being taken to use those lemedies undei \eiy
careful aseptic conditions, othci .ippiopnatc
nervine tonics arc called foi
Dropsy, Epidemic.
tire also BERTBEHI
liETWtEN the yeais 1877 and 1880 theio broke
out m (Jalcutta a peculiar disease to which the
toim cpidcmu dropsy \\us .ippliod Tho disease
only occunod dining the cold \\eathcr, and <t
suuilai outbioak \vas noted in Mainitms and
Assam in 1878, and at IXicca and South Sylhot
in the cold season of 1878-79 The best account
of the condition has been given by M'Lood, who
described the cases as scon in Calcutta, (Trans.
Epid <S'oc vol xu )
The mortality there was as high as 20 to
10 pet cent, while in tho othci districts the
DROPSY, EPIDEMIC
423
mortality was trivial in comparison with these
figures.
At the time of its occurrence the condition
was regarded by many to be mciely that type
of beiiben in which dropsy is a pronounced
symptom, the nervous phenomena being very
slightly maikcd, but M'Leod concluded thdt it
was a distinct entity As no fuithei outbreaks
have been recorded, oin knowledge of the disease
has not increased Little in known regarding
the moi bid anatomy and etiology, but the fact
of its communicabihty and the histories of the
successive outbreaks furnish evidence in favoui
of a germ theory
The disease ran a rouise of from thiee to six
weeks Dropsy, amemia, and fever formed the
caidmal symptoms, these usually being accom-
panied by great geneial w eakness, w astmg, breath-
lessness, diarrhoea, -\omiting, and vsiious nervous
symptoms The amount ot antenna and dropsy
present gave nse to the term acute anamiic
dropsy Tho diopsy was usually, but not in-
variably, pieceded by the febrile and othei
symptoms hereafter lufeired to The onset ot
the ojdcma was sudden, and fnst showed itself
in the legs, and in scveie cases soon became
gcnenil, with the development of extensive
pleural and pel icaidial effusion w ith oedema of
the lungs A distinct tendency lo recuneiicc
of the drops} aftei its disappearance \vas noted
in home c«ises A remittent type oi fever was
present, not usually high, but \ aiding from
99J° F to 102° F , and the time of its occurrence
t>ore no apparent constant relationship to the
development of tho dropsy Alimentary dis-
turbances, notably diarrhoea and vomiting, and
also nervotw symptoms, PI/ amusthesia of the
bkm, itching, and paiesis of muscles, weie occa-
sionally met with, but were not common An
eiythematous skin ciuption not infrequent!}
appealed about a week after the oxlcma In
fatal cases death was sudden, and Mas duo to
the pulmonaiy and cardiac complications
The points on \vlnch stiess was laid in support
of the view that the disease is distinct fiom
beiiben are — The acuteness of the affection ,
the piescncc of well-marked fever, and the skin
eruption , but it must be admitted that fuithei
information is wanting befoie the distinction
can be fully and finally dtawn (imle " Beriboit ")
Treatment — Fiom out ignoianceot the cause,
treatment must be conducted simply on the
goneial medical principles laid do\vn in that
article.
Drowning*. See ASPHYXIA , MEDICINE,
FORENSIC (Death from Aythyiui) , MEMORY IN
HEALTH AND DISEASE
DrOWSlneSS. See BRAIN, AFFECTIONS OF
BIOOD- VESSELS (Anaemia), BRAIN, SUHOER\ OF
(Cerebral Abww, Drownness) , SIOMACH AND
DUODENUM, DISEASED OF ((tenet al tiymptmnato-
loffy, Remote tiymptomi)
Drug Eruptions.
INTRODUCTORY
T^ PES OF KRUPTION
ETIOLOO\
DIFFERENTIAL DIAGNOSIS
TREATMENT
DRUOH
423
424
424
425
425
425
Antifebrin, Antipyun, Aigenti mtias, Arsenic,
Belladonna, Benzoin, Boric acid, Bromides,
Cannahis indica, Chloral hydras, Copaiba,
Culxjbs, Ergot, Iodides, iodoform, Mercury,
Morphm, Quinine, Salic} lie acid, etc , Sul-
phonal, Tar
AM 11 ox IN RASHES, etc . 431
See nlw BLILADONNA , BROMISM , DERMATITIS
TRAUWAIICA ET VJABNAFA , PHARMACOLOGI ,
I'URPUiiA (Taj ic) , UUBELLA (Druff Ra*h) ,
TOXICOLOGY , and undei some ot the various
Drugs themselves
THAT eiuptions follow the external 01 the m-
teinal use of dings in certain classes of indi-
viduals is a fact with which all deimatologists
are familial , but in the intensity of the reaction
pioduccd vanations occiu within wide limits,
so that, in conjunction with the pel son al idiosyn-
crasy, frequent modifications of type may IH*
expected, and, indeed, aie almost invariably
found In certain persons the exhibition of a
given ding in any foim acts as a poison, while
in otheis, and piobably the majority, no toxic
effects aie pi od need , and it must be borne in
mind in this connection that tho occuirenco
of ccitam constitutional diseases modifies in a
maiked degree in many cases the action which
occuis dm ing administration, or even produces
a soit of immunity — in other woids, cieatcs in
the mdiMdual a ceitain toleiancc which could
not be acquned mulct the noimal conditions of
freedom from disease This is best exemplified
in the increased resisting power to the action of
both men in} and the salts of iodine shown by
the \ast ma]onty of syphilitic patients It is
obvious, therefoie, that in considciing the general
question of drug eiuptions, two most important
f.ictors must be constantly boiue in mind first,
the natural, 01 acquit cd, immunity enjoyed by
i ei lain individuals , and, secondly, the pecuhai
susceptibility from which othei persons suffer —
the cause in either ease being equally undetei-
minod and indeterminable
Drug eiuptions ate dnided by natuial lines
into two great classes (a) ttaumatic deniiatose*,
those produced by the action of irritant or
poisonous substances coming in dnect contact
with the skin, which may be parasitic, animal,
vegetable, or inorganic in natuie, and (6) the
t<>jnc<kimatose^ those cutaneous manifestations
which follow in (Oi tun individuals the internal
admimstiation of various drugs The former
class will only be incidentally alluded to here,
as it has been aheady dealt with (see " Dermatitis
424
DRUG ERUPTIONS
Traumatica ") ; and our attention may there-
fore bo wholly fixed (A) On the nature and
varieties of the eruptions produced by the m-
gestion of medicinal substances, and (B) in
detail, on the various more important drugs
associated with the occurrence of skin lesions
It is clear that in an article of this scope no
exhaustive treatment of the subject is possible,
and therefore only the more frequent forms of
drug eruption will be dealt with
A Considering the variety of substances
which in their assimilation 01 elimination arc
capable of giving rise to such eruptions, it is not
A matter of wonder that the forms assumed do
not conform to any one type, but are in the
widest degree polymorphous .ind interchange-
able Thus similar lesions may be produced by
different drugs in different individuals , or erup-
tions widely different produced by the same drug
in persons whose individual susceptibility defies
computation. In fact, m these cases no class of
skin lesion has been left unexampled , and, while
in the majority of cases they are erythematous in
type, they are capable of all the variations which
are met with in that largo and inconstant group
They may simulate the acute exanthems of
measles, variola, scarlatina, or rotheln , they
may mimic with startling occmacy tho foims of
cutaneous erysipelas, they may bo erythematous,
papular, urticarial, vesiculai, pustular, bullous,
or oven gangrenous, according to the degree of
reactionary inflammation elicited m the given
individual Hence, in many instances, the diffi-
culties which surround the diagnosis and the
errors into which those unacquainted \vith the
polymorphous lesions have been led. Thus cases
have been recorded in which fatal results followed
the administration of the iodides, the patients
succumbing to a bullous and gangrenous derma-
titis induced by progressively increasing doses
administered for the cure of an imaginary
syphilide
The following tabular list, in which the effects
following tho external application of drugs have
been compared with those icsultmg from then
internal administration, may prove useful foi
purposes of reference —
TYPES OP ERUPTION AND DRUGS A&HOCTATED
WITH TiiEiit OCCURRENCE
1 Erythematous
(a) From External use — Aconite, Arnica, Balsam
of Peru, Boric Acid, Carbolic Acid, Chrysaro-
bm, Croton Oil, lodoform, Oil of Cade, Tar,
Turpentine
(b) Front Internal use — Antipynn, Antitoxin,
Arnica, Arsem6, Belladonna, Boric Acid, Bro-
mides, Chloral Hydrate, Copaiba, Cubebs,
Hyoscyamin, Iodides, Morphm, Quinine,
Phenacctin, Rhubarb, Salicylic Acid, Stoa-
monium, Sulphonal, Tar, Turpentine
2 Papular, Vesicular, Pustular (mwed, con-
fluent, and exaggerated forms).
(a) From External u*e — Aconite, Antimony,
A mica, Bichromate of Potash, Canthandes,
Caibolic Acid, Chrysarobm, Oil of Cade,
Croton Oil, lodoform, Ipecacuanha, Mercurial
Stilts, RhiiH Toxicodendron ("poisoning"),
Sulphur, Tar, Terebeue, Thapsia.
(b) From Internal UK — Aconite, Antimony,
Arsenic, Borax, Bromides, Cannabis Indica,
Chloral Hydrate, Copaiba, Cubebs, Digitalis,
Ergot, Iodides, Iron (principally tho iodide),
Quinine, Snlphm, Terebene |
3 Urticarial.
(a) Ftoin External iite — \comte, Balsam of
Peru
(f>) From fnttind? u*e — Autipyim, AntimonjT,
Bromides, Copaiba, Iodides, Quinine, Mor-
phin, Santonin, Sulphonal
4 Pig mentai y
(a) Fiotit External ut,e — riirysaiobm, Picric
Acid
(b) From Internal use — Argenti Nitras, Arsenic,
Autifebrm
Regarding tho etiology oi these ei upturns but
httlo is definitely known It has been hold that
they are due to an elimination of the toxic sub-
stances themselves, or of some subtle compounds
formed fioin them in tho tissues, by means of
the cutaneous glands, especially the sebaceous
follicles , and suppoit of this vie\\ has been
sought foi in the tact th.it the tendency towards
the development of such lesions is Lugely aggra-
vated in cases of ien.il or cardiac m.idequacy.
This, uhich means a compensatoiy el mn native
activity of the skin glands, piosupposes a ceitam
degree ot saturation of the system with tho
drug , but clinical experience goes to prove that
to\ic dermatoses aie just JIN likely to occur m
cases where only a few, and those minimal, doses
have been gnen, us in cases where a certain
amount of accumulation has taken place from
prolonged and continuous administration Sti ess
has also been laid on the fact that in some cases
traces of the oflendmg ding (eg biomme, iodine,
etc ) have been detected in the secretions of the
skin , but these obseivations have by no means
been universally confirmed, which would be
essential to the establishment of the postulate ;
while in nearly all cases evidence of tho elimina-
tion of the drug in tho mine can be obtained.
Further, histological examination has shown
conclusively that the cutaneous lesions are not
confined to, or even mainly manifested in con-
nection with, the glandular apparatus of the
skin The neighbourhood of tho blood-vessels
shows the most pronounced changes — general
hypericmia, and small multiple inflammatory
areas, which often become abscesses of micro-
scopic size , while the glandular structures — the
DRUG ERUPTIONS
425
coil glands, aud more cspcciall) the sebaceous
glands — arc only to a small extent, and that
secondarily, affected It may also be pointed
out that the distribution of wich i ashes is often,
indeed in the majority of cases, confined to a
limited au»a, and docs not piesont the univer-
sality of ,i cnculatoiy poison, and Moriovv has
diawn attention to the fact that veiy many of
the drugs associated \\ith skin eruptions have a
know n influence upon the nervous sv stem, either
by dnect action upon the pcnpheial none end-
ings 01 on the nemo- vascular centies We are
therefore diiven by a piocess of exclusive leason-
mg to the conclusion that in all these cxanthema-
tous lashes piodiiGod bv diugs we have to deal
with "a \aso-motot nouiosis cither fioni icflex
irntation (i e from the ponpheial nei\e endings)
or from dnect action 011 the vaso-motoi centies '
(Crocker) But above all it must be constant!}
borne in mind that, in .ill cases almost, the
determining factoi is the "pcisonal equation,"
than which no moio "variable or elusive quantity
<-an be found in studying the causation and
lemoter consequences of disease
A woid must be said hwo as to the differential
ilwtfiuMi ol ding eiuptions in general fiom the
particulai cxanthematous i ashes they simulate,
— .1 point of the greatest clinical importance,
and, indeed, the only one which laiscs these
manifestations above the tool of phaimac outic «il
curiosities In the funnel case thoie is a histoiy
of the .ulmmist ration of the dnm, aud there aie,
<is a tule, no constitutional complications In
the case of copaiba lash, which most closely
lescmblt's that of measles, the ei upturn supci-
\enes suddenly without anv precedent fevei
or coryza, though it should be noted that flushing
of the face aud injection of the conjunctiva may
occur In the searlatmifoi m lash pioduced by
belladonn.i, quinine, et< , theie is no fever, no
sore thioat, though there mav be vivid tcdnoss
of the fauces, and no glandulai complication ,
and the same icmaik applies equally to cases
where the ciuption moie closely losomblos that
ot Geiman measles It is haully possible that
any of the pustul.u foims could be mistaken foi
variola , but the surest v\ay of escaping mistakes
in all cases is an acquaintance with the perfect
mimicry v\ith which the exanthcmatoiis i ashes
are copied m many of the foims of eiuptions due
to drugs The avoidance of emu is only
possible \\ here the knowledge of its likelihood
exists
B DRUGS WHICH I'ltoiiuiE Toxic- ERUPTIONS
— In dealing with the drugs whuh aie most
frequently concerned in the production of these
varying eruptions in fuller detail, we have placed
them for convenience of reference in alphabetical
sequence The symptoms associated with the
development of each will there be given, and
also the indications for any special, general, or
local treatment, which has either piovod of
specific value or of benefit in alleviating symp-
toms1, undei the heading of each particulai drug
The general principles of treatment will be
referred to at the end of this section
Anttfeltrtn (Acetanihde) --A lash, somewhat
resembling that of measles, has been descubed
as following aftci the internal administration of
this drug, even in doses of ten giauis When
its use has been continued over a lengthened
pel lod, 01 given in lai ger dosos ovei a restricted
time, a pccuhai cyanosis is induced which has
been described as resembling a " slaty-coloured
anemia" There aie no constitutional sv.mp-
toms, and no alteration m the colour ot the
mine ]
dnitpytta (phena/one), when given internally,
piod IK es m .i huge pioportion of cases a
| Mitareous ciuption— the pioportion varvmg
i ion 2 pci tent m men to 7 per cent in women
j It is most frequently moibil'iform in type,
' affecting the extensoi more than the flexor
I aspects, and the extremities nioic aggiessively
, than the hod} Its s>mmetiy is usually well
, dehned , and it is associated with pi of use swoat-
1 uig, model ate itching, and a ceitam amount oi
subsequent desquamation A distinctly mti-
caiial t}po has also been obseivod , and in
exceptional cases the fonu assumed has been
that of a purpunc 01 bullous eiuption These
vanous results aie probably brought about by
the action of the drug in causing paiatysisof
the vaso-motoi neives, and thus leading to the
picsome of a laigely increased amount of blood
1 in the vessels of the skin The eiuption genei-
ally disappeais lapidly on the immediate discon-
tinuance of the drug, moie slowly when it is
given in giadually deci easing doses
Aryenti nit i as The peculiar bluish - giey
disooloiatinn of the skin produced by the lon,.»-
(ontinued admimstiatiou of mtiate ol silver,
and embraced in the term "aigyria," is the
1 most commonly observed lesult of the drug,
| though Thai cot has dcsciilnxl an itching and
j ei \ thcmato-papular eiuption .is having followed
its use in a few cases It must be bonie in
mind, how ovei, th.it its mtcinal use as a medi-
cine is not necessaiy foi the production of the
• skin discoloiation, as this icsult may follow the
j habitual application of a solution of the salt to
mucous surfaces , as, for example, in chiomc
thioat attoctions The deposit ol silver, 01
silvci combination, in the skin "is always cou-
i fined within exact limits to the margin of the
connective tissue, and specially affects the elastic
tibies and the lesistmg limiting membranes,
avoiding altogether the protoplasmic paits of
i the connective tissue, and the epithelium with
I its appendages" (Tuna) It is stated that tho
i prolonged admmistiation of iodides given m vciy
! dilute combination with mineral waters (Vals,
Vichy, etc ), along w ith massage in warm baths,
aids in tho elimination of the silver , but this is
1 The drugs winch induce marked alterations in the
unno will Tie referred to under " Urine "
426
DRUG ERUPTIONS
doubtful, and when the deposit has attained a
certain limit, its removal is hopeless
Arsenic produces skin manifestations of \ dry-
ing degree eithei by local contact 01 by ingostion
The former aie especially been amongst thobo
w ho work in it, either in the crude foi m, or in bonic j
of those numerous articles of commeice in the
manufacture of which it plajs bo important a
part Thus they aiu met with in thobc engaged
in the manufacture of artificial floweis, card-
board boxes, etc , and in those who wear stock-
ings or other articles of underclothing d>ed \vith
the cheaper colouiing matteis \\hich often con-
tain arsenic in a poisonous degice In othei
cases these eiuptions have followed the iihe of
skin lotions and cosmetics The results of its
internal administration aie various, and immei-
ons types have been described An ei ytfieinatoin
type rebcmbhng erysipelas, ard often becoming
vesicular, affecting mainly the face and eyelids,
which become congested and wdematous, is one
ot those mobt frequently met with Another —
the fxipular foim — appeals mainly on the iace,
neck, hands, and about the genital oigans At
first the papules are few in number and small,
occurimg in stuttered groups which subse-
quently eithei enlaigo or coalesce to foim
disseminated patches ot irregulai outline that
may bcai a close resemblance to a papular
syphilidc, though the coppery line is loss
pionounced ot absent altogether (linbeil-
(tourboyre) The1 itrttcminl type has boon
frequently obsei vcd, and differs m no essential
particulai from the well-known wheats and
associated symptoms of oidmaty nettlc-iash
The venridat form is now well iccoguised, some
times resembling ec/ema of an obstinate char-
actei, and such as one meets with in ordinal y
cases ot "weeping eexemu " Hutchmson fiibt
directed attention to the comparatively fre-
?uent (HLiinence of attacks of hoipes /ostei
"shingles") in persons taking arsenic IJis
obseiAations have been extended and contained
by Nielsen, who found th.it ot 5f>7 eases of
psoriasis tieated with arsenic in the Copenhagen
General Hospital, ncaily '2 per cent (I 80)
sufteicd from heipcs, whilst among those tieated
without arsenic not a single case occmrcd The
i elation of arsenic to the production of pen-
pheial neuritis is well known, and fmmshes an
explanation of the etiology of zoster in those
cases A pustulat foim has also been observed
to follow the admimstiation of the drug, finding
its termination m the development of crusts 01
ulcers which heal slowly with pennancnt scar-
ring Moms has noticed the occurrence of boils
and carbuncles, an observation confirmed by
othei s, which points to a graver degree ot
pyogenetic infection, or may IKS duo to an acci-
dental inoculation Thickening of the bkm ot
the palms and soles is alboj seen, the indura-
tion beginning aiound the sweat follicles, and
gradually extending thence peripherally until
a umfoim condition of keratons is produced
Hutchmson has directed attention to the tend-
ency this induration shows to ulceration and to
the subsequent ultimate development of epi-
thehoma. It is obvious, therefore, that m the
multiplicity of lesions produced by arsenic great
discrimination is essential, the ultimate tost in
eveiy case being the disappearance of the erup-
tion on withholding the drug In the pustulai
or ulcciative condition the use of soothing or
antiseptic lotions may become a necessary ad-
junct to tieatmcnt
Belladonna (atropm) produces a diffuse erj-
thematous blush which is mainly limited to the
face, neck, and upper part of the thorax, and
which only lately becomes generally distributed
It is of a vivid icd ness and closely simulates
the e\anthem of scarlatina It occuis for the
most part (leaving aside cases of poisoning) m
>oung child i en with cleai, tianspaient skins, is
extremely evanescent m duiation, and is not
follow edb> desqiiamiition ('looker states that
he has rarely seen the eruption following medici-
nal doses, but agrees with its occuirence in
(ascs of ]K>isoumi* by the drug The use of
atropm m eye piartice is occasionally followed
by a scveie inflammation which stiikmgly
icscmbles eiysipelas Fox has called attention
to the fact that the diffused scarlatmiform lash
may be seen occasionally to follow the extcinal
application ot belladonna in some of its picpaia-
tions, such as the emplasti uni or gl) conn The
point of chief clinical impoitance is to diagnos-
ticate between this ding lash and that of
scarlatina, but the, factois ahe.uty mentioned,
when no epidemic is prevalent, especially the
absence of piodtomal symptoms, Dne fleeting
natuie of the erjthema, and the usually almost
noi mal tcmpeiatmc, can hardlv, if cai chilly
weighed, leave any possibility of enoi
linr.oin — In the toim of fiiai's balsam,
oideied foi inhalation, Fox has observed the
occurrence of a pmpuiic erythema, which was
confluent upon the tiunk, but more discrete
upon the extremities Ben/oic acid given in
small quantities has been known to produce a
lose-colourcd maculo- papular eruption, which
I disappeaied on discontinuance of the drug ,
i and several cases have been noticed where erv-
I thematous i ashes, attended with itching and
followed by slight dcsquamation, have resulted
from the administration of ordinary medicinal
doses ot benxoato ot sodium
Jioric Add — Eiy thematous rashes, followed
in a certain number of cases by even fatal
lesults, have been icpoited as a consequence ot
the absorption of bone acid from washing out
cavities, generally serous, with Lugo quantities
of the drug in solution Impotigmous eruptions
have also followed its internal administration
The boiate of sodium, given in 5-gram doses
over a long penod, m cases of epilepsy, has been
observed by Gowors and Livcmg to give nsc to
DRUG ERUPTIONS
427
a psoriasis which differs in no respect from the
usual chronic type
Jhomme and the Jironwles — 1'iobably no
variety of chug ci upturn is more frequently
observed, 01 is capable of wider variation, than
that due to the administration of the halts of
bromine In general characteristics the rashes
produced icscmble tlohely the group ot iodine
cmptious to be considered subsequently , but
they always present shades of diffeience to the
accustomed eye, and two important points of
differentiation in gcncial are these — they .ire
always much slower in development, and they
are much less likely to become confluent over a
large area and to assume a billions or gangu nous
type In form they lange ovci the whole
nomenclatuie of pnmaiy skin lesions, and may
be pustular, erythcmatous, urticanal, billions-,
01 squamous in type — the above sequence in-
dicating approximately the lelatue ordei of
frequency
The paj/iiloyu&tulnr ioim— known as " bionnc
acne" — is the most frequent, and occuis in
about 75 percent of all persons taking potassium
biomide Jt appears most commonly on the
face, chest, back, and in the neighbourhood of
the hair follicles of th»» thigh and leg , and it
may vaiy between the e\tieme,s ot being in the
simplest form tlivwfe and acne-like, and m the
gravest ioim confluent and fuiuncular, though
between the&o e\ti ernes many dcgiecs of \aiia-
tion mill be found The pustules aie yellowish
in coloui, se.ited on an infiamcd base, and difler
from those oi simple acne in that the} appeal
without the necessaiy pic-existence ot come-
dones, and they aie not confined in distiibution
to legion v wheie i>landulai structuies natuially
occur They \aiy m size within wide limits,
and in the confluent tjpe they meige into oath
othoi, foiming conglomeiate gioups, and giadu-
ally increasing in si/o l»v the extension of their
maigins until they ma^ eventually covoi a
considerable area In tlie meantime the contents
diy up and become co\eied \\ith bio\vmsh
ci usts which .110 ele\ itod on a /one of sur-
lounding eiythcma, and which tend to become
associated with a distinct and definite h\pei-
tiophy of the undenting p.ipillaiy Ixxlies
This is the foim to which lTnna has spocific.illy
applied the toim btomotlumn jm<*tu1o-tnlnto*Mm
The disci etc form dilteis from ordinary acne in
that the inflammation is gcneially moie acute,
the lesions suppuiate moio lapidly, and the
contents are of a moie seio-pwulenl type In
the confluent foim the piesence of numeious
pustulai points on a raised, soft, dusky-icd, and
painless base, and the disappearance of the
lesions undci a scab without the formation of a
scar, but with a slightly persisting icddish-biown
stain, serve to differentiate it fiom all othei eiuji-
tions except those due to the iodides (Crocker)
It is probable that individual idiosyncrasy
plays a less important pait in this than in the
majority of other drug eruptions, hence its
universality and the uniformity of its main
characteristics It is known that elimination
of bromine takes place through many glandular
tissues, principally the kidneys, and m a less
degree by means of the salivary, sweat, and
mammary glands, w hen the lattet arc function-
ally active, as witness the many lecordcd eases
in which symptoms of bromic eruption IMIAC
occiured in infants suckled by those taking the
ding On this analogy it has been argued that
the skin manifestations arc due to its elimina-
tion by the sebaceous glands, but many facts
piCMously lefeired to throw doubt 011 the
genuineness of this hypothesis In connection
with this theoiy attention may be directed to
the fact, pointed out by Ciotkei, that the
eruption \eiy frequently begins m seal tissue,
IxMiig even occasionally limited to it, a favourite
site being in "\ at dilation scais It is needless
to point out how entirely this is opjx)sed to the
iundamental premiss on which the theoiy of
glandulai elimination is based ft may be
mentioned heic, in oidci to avoid erioi, that in
some cases the lash onl\ makes its appearance
aftei the discontinuance of the diug, and that
also, as m the case oi the iodine eruptions,
where theie is idiosynciarty, small doses aie moie
likely to evoke the symptoms than largei ones.
In this, as in most ot these diug aflections,
the main indication of ttcutmrnt is to stop the
cause The admmistiation ot liquoi aisemcalis,
.}-~>n\, two 01 thiec times flail v, is said to act
as an clinmiant Local applic.it ions, such as
lead 01 c\apoiatmg lotion, 01 salicylic acid
(m j ad jjj ) on hut co\eied with gutta-pcicha
tissue ma\ lie icquued when the inflammation
is seveie 01 the skin suiface biokeu Liquoi
at sen it alls, 01 some picpaiation of ammonia,
sut h as tlie caibonate oi the aiomatic spirit,
adtled to the piescnption containing the
hinnudc, is said to maikedly dimmish li not
entnel} pi event the tendency tow aids the
development of the emption In icgard to
the stoppage ot the bionndc in these cases it
should be lemembeietl that eminent authoiities
ha"\c laid down as a positne l.iw th.it a duect
i elation exists between the intensity of the skin
ei upturn and the efficacy ot the diug as a remedy
in the disease foi which it is admin istcied This
again is a point which can only be determined
by careful and mdnidual obseivation
Cannaln Indna — In one leeoided case an
acute A esiculai ei upturn of A cry w ide distiibution
followed a dose of one i>ium of the extiact It
subsided in the couisc ot a few dajs, the vesicles
drying up and leaving <i usts which gradually
fell oft (Hyde) (Kdoma of the face has been
noticed as one of the sjmptoms of chronic
intoxication with this diug
Chloral Hydiate—'£\w local effect of chloral
as a cutaneous \esir ant is well known, and it
has been largely lecom mended in certain cases
428
DRUG ERUPTIONS
as a substitute for the prepaiations of can-
thandes , but considering the large number of
affections in which it is employed internally it
cannot be generally recognised as a frequent
producci of cutaneous eruptions In its special
features the rash usually appears within a shoit
period, has only a very limited duration, <md is
unaccompanied as a inle by constitutional 01
local disturbances, though in some cases itching
or irritation has been observed The rash when
it occurs is generally erythematous in type, but
may present the appeal am e of dusky-icd papules
surrounded by an area of diffused ledncss ex-
tending about the affected paits, which aie
mainly the face, neck, and neighbourhood of
the Urge articulations In some cases it may
be morbilhform in character, and mticaiial,
vc&iculai, and petechial foims have also been
descnbcd A remarkable relationship exists
in all the foims between the ingestion of food,
and more especially of alcohol, and the develop-
ment of the lash This has e\cn been observed
in children taking the ding, \vhen alcohol, in
the form of a tincture, has been pi escribed in
combination In all cases the effects produced
are piobably due to the influence which rhloial
exerts upon the vaso-motoi system
Copailta — The t\pe of the eiuption is maiulv
eiythematous and papulai, or moic essentially
morbilhform, with a special piedilection foi the
neighbourhood of the hands, aims, feet, knees,
and abdomen In its most chaiacteiistic form
it consists of " rosc-colonred, nregulai patches,
grouped 01 diwiete, and only just peiceptibly
uused above the sin face" The ledness dis-
appeais completely on pressure Intense itching
may be present, and a foim which successfully
simulates urticaria is well known The lash
fades lapidly on withdrawal of the diuir, and is
succeeded by slight desquamation These foims
are commonly met with, and may follow the
admin ih tuition of the drug fin gcnito-uiinaiv
conditions or foi chronic chest affections It
is probable that in the majority of («ises the
cutaneous manifestations are due to the elimi-
nation of the ^volatile oil by the sweat glands,
but in the iirticai lal form they may be due to
the gastric nutation \\hioh is so constantly
associated with the use of the drug, and which
is so largely a fuctoi in the production of
ordinal y nrticana \s curiosities of deima-
tology, vesiculai, billions, and petechial erup-
tions h.ive been described as sequelrc to the
administration of copaiba Clinically its nn-
poitance consists in the differential diagnosis
between the drug eruption and the rash oi
measles, of rothcln (rubella), or of an erythe-
matous syphibde
Cubefa, which if1 much less extensively used,
in this count ly at least, than copaiba, produces
in a few cases smnlai cutaneous manifestations
which do not require separate description
Ergot — The subcutaneous injection of eigot
not infrequently induces a painful, dark-colouied
swelling at the point of puncture. Erythema,
with swelling of the parts, vesicular and pustular
eruptions, and gangrene of the extremities, may
occui from its internal administrations, but the
lattei larely from its use in medicinal doses.
Iodine and the Jodide* — ChaiactcriHtic types
of these eruptions, to be described picscntly in
detail, have resulted fiom tho external applica-
tion of iodine, such as repeated painting of a
pait \vith the tincture or liniment, or the
injection of some such preparation to excite
inflammation in a seious cyst, but thoy aie
most frequently obseived to follow the ingestion
of some of its alkaline salts, even in tho most
minute doses — and iodide of potassium, tho
most frequently adimnistcicd, may be taken in
its effects for the whole group It may be here
incidentally stated that, accoidmg to many
observers, the sodium salt is the least and the
ammonium salt the most actno in p wincing
cutaneous manifestations, and that in many
cases of pronounced idiosyncrasy the strontium
salt may be taken with impunity In all the
varieties of drug eiuptions no more con-
glomerate group can be found, and it is just
this absence of clinical unanimity which renders
their leeogmtion difficult and at the same time
imperative, for in several cases fatal results
have followed from ignorance of the cause
which determined the skin lesions As Morzow
well puts it, "iodide of potassium may be con-
tinued, possibly in increasing doses, for the
>ery condition which it has caused "
No moie polymoiphous eiuptions aie known
to dermatology than those due to the iodine
compounds As in the case of tlfr bromine
salts, the commonest foi in is the pustulai, but
other typos met with aie the erythematous,
\esiculai 01 bullous, uiticanal, and j)iirpuiic
\arioties, the two lattei belonging to the < ategory
ol dermatological ( unosities
The most fiequent ot all is that to which
Tuna has applied the teiiu lododeruui jwtttiltt-
tuberovun The lash begins act small papules
rapidly becoming pustulai, and occur i ing most
ficquently on the face, upper pait of thoiax in
fiont and behind, and sometimes on the ex-
tremities In its eaily stages it closely simulates
the bromide eiuption, to which the false teim
" bromic acne " has been comnioiil} applied.
These lesions may remain discrete oi become
confluent, and so merge into some of the more
aggra'iated types That the eiuption is not
due to glandular elimination has already been
stated, its distribution does not always coi re-
spond to that of the supposed eliminating
glands, nor does it piesent the universality and
symmetry necessary to a circulatory poison
Microscopic examination of evcised portions of
skin has further shown that far from elimination
taking place from the sebaceous follicles, as
would be evidenced by marked changes there,
le foci of greatest inflammation are situated
>mewhat superficially in the skin, where they
>ngregate into microscopic abscesses. That
lese may burst into the follicles and so appear
a the surface is of course possible, but in the
tultitude of cases examined such an accidental
Dmmunication has never been found. It is
lerefore highly probable that the causation of
le pustular surface lesions is not to be met
ith in the glands ; and, moreover, the absence
f iodine from their contents in the great
wjority of cases is strongly against the pre-
emption of such a relationship. So far as
resent observations lead us, it seems safer to
3gard the skin manifestations as being due to
vaso-motor neurosis induced in some unknown
-ay by the action of the drug ; and to this
Iso the consensus of histologieal opinion points,
'ho only constant changes on which all observers
re agreed are, marked dilatation and some-
mes thrombosis of the cutaneous blood-vessels,
ith alteration and partial destruction of the
oil-glands; while, on the other hand, the
3baceous glands and hair follicles are only in
lolated instances, and but to a limited extent,
ivolvcd in the inflammation.
The papula-pustular form usually begins as
cnall shot-like papules which resemble some-
rhat the earliest stage of the variolar rash, a
^semblance which is much increased as they
ecome vesicular, when they also show a marked
sndeucy towards umbilication. They quickly
ass into a pustular stage, the pustules being
lore acuminate than those of the so-called
bromic acne," and being seated on an erythe-
latous and somewhat infiltrated base. The
•liter has eeeu the eruption resemble in a very
larked degree the vesicular eruption of herpes
rater, and, like it, leave on drying up and the
absequent separation of the crusts, a small but
istinct whitish scar. The seats of predilection
re the face, the upper part of the thorax in
•ont and behind, and, less frequently, the ex-
remitios. From these primitive forms all
ogrees of development may be met with. The
pots may become confluent, resembling the
romide eruptions, or may tend rather in a
ullous direction, the contents of the bulloo re-
laining clearer than in the analogous bromide
sion. In rare cases the confluent form is
asociated with epithelial proliferation and a
vaulting papillomatoua upgrowth, and when
> this is added the introduction of pyogenic
rganisms and the formation of pus, which dis-
tiarges through multiple small openings, we
ave the condition described by Besnier as
acnt anthrato'ide iodo-potassiquc." In a case
escribed by Duhring " there was a confluence
f the nodules, • forming a sharply defined,
)unded, inflammatory patch, violaceous in
dour, its centre depressed and crusted, while
le periphery was studded with deep-seated,
ellowish, sebaceous-looking pustules, presenting
an acneiform appearance." The vesicular and
bullous forms are much less frequently met
with ; while the urticarial tmdpurpuric varieties
may bo regarded solely as society show cases. The
condition described by Hutchinson as " iodide
hydroa" is simply an exaggerated form of the
bullous eruption. A fatal case of the purpuric
form occurring in a young child and following
a dose of 2 J grains has been recorded by Stephen
Mackenzie, and illustrated with a capital plate.
No fixed relationship in time can be laid
down as existing between the administration of
the dnig and the appearance of cutaneous
symptoms. It varies largely in different cases,
and depends among other things on two main
factors: firstly, the relative susceptibility of
the individual; and, secondly, the amount of
the drug administered. But it has been already
pointed out that the latter bears very little
relation to the occurrence of skin lesions, because,
as has been observed, tolerance of large doses is
sometimes seen in those who react promptly to
the drug in a minimal dose. Nor has elimina-
tive activity any except a secondary relationship;
because it hat* been shown that, on the one
hand, vascular or renal inadequacy presupposes
a saturation which we know does not exist, and,
on the other hand, that the cutaneous symptoms
may not manifest themselves for a considerable
time after the drug has been suspended. This
feature of dosage has been explained on the
ground that, when given in large quantity,
iodide of potassium acts as a diuretic; while
on withdrawal or reduction of quantity this
oliminativc activity ceases.
As regards treatment, what has been said
under the bromide eruptions applies equally
here. As a prophylactic measure the most
valuable, beyond doubt, is the free dilution of
the drug with largo quantities of natural or
artificial mineral waters, of milk, or of other
diluents. The graver forms, besides stoppage
of the drug, may require tonic and stimulant
treatment, owing to the powerfully depressant
effect it has in many cases.
lodoform does not usually give rise to any
skin manifestations when administered internally,
or injected as an emulsion into the joints or
subcutaneous tissues; yet in some cases the
extension of the eruption spreads so far wide of
the area of application that many dermatologists
regard it as a constitutional intoxication quite
apart from the local dermatitis caused by its
direct application. This may be a punctiform,
eczematouts, or vesicular eruption, spreading
with a rapidity and an advancing border of
vivid redness almost indistinguishable from
erysipelas. Here again idiosyncrasy counts for
much ; and the writer has geen one case of
rodent cancer in which a second application of the
powdered drug reproduced, after an interval of
five years, with absolute exactitude the features,
of a previous attack due to the same cause, viz.
430
DRUG ERUPTIONS
an acute vehicular erythema in the central parts
with a penpheral vivid rod and infiltrated
border closely resembling erysipelas In the
diminishing use of lodoform since the piactice
of aseptic surgery has become more geneial
these eruptions arc less frequently seen , but for
that very reason it is the moii1 necessary foi the
practitionei to bo familiar w ith then occurreiu e
Met cut y — Since the intioduction of anti-
septics into the ti (fitment of wounds eveiy
student has been familui with the eruptions
pi od need by the local action of various mcrcuual
salts upon the ,»km These ate most commonly
erythematous, \csrcular, or pustular, 01 fre-
quently a combination of all thiee The vesicles
aie minute, extremely numeious, and almost
always become pustular, especially when situated
close to the pilo-sebaecous follicles of the skin
But neaily a century ago Alley called attention
to a condition which he called Ilydmtyyim,
following upon the internal admimstiation of
mercuiy, and which he grouped undei tlnec
main headings as regarded type — the mild, the
febrife, and the main/mint It may be noted
here that the association between these eruptions
and the internal use of the (hug has been denied
by one of the highest authorities , but the
obscivations of by far the large majority ot
modem dei matologists amply (ontnm the oldei
teaching Almost any ot the ptcpatations of
mercury may give rise to cutaneous s\mptoms ,
but by common consent the one most frequently
found to produce them aftei internal admmis-
tiation is calomel Although Alley's classification
is not no\v generally adopted, most observe is
aie agreed upon the occurrence of t\vo well-
<lefined forms — a im/d and a tfinve The former
is simply an acute e< /omatous iash accompanied
ii ith intense itching and the formation of
vesicles, and most frequently distributed on the
inner sin faces of the thighs, the scrotum, the
groin, and the lowoi pait oi the abdomen The
</rttvt form is meicly .in e\.iggcrated type of
this, in whu h the vesicles become pustular 01
even bullous, associated with considerable fever
and general malaise, and sometimes with acute
inflammations of the i elated lymphatic glands
Desquamation follows as the patches diy up,
and in raic cases lepe.ited exfoliations may
occur It is highly piobable that in the
glandular cases pjogenic infection has been
grafted on by the sciatchmg of the inflamed
and itching sin face Stoppage of the cling is
generally followed by lapul subsidence of the
symptoms , but wheie the irritation is great
the application of calammc lotion or dusting
the part with powdcicd staich and oxide of zinc
af folds great ichef
Morphm has l<jng been known as having an
nrit, in t action on the skin, and pruritus opti
was familiar to the earliest wiiters When a
rash is associated w ith the tingling and itching
of the skin it is invariably crythematous, re-
sembling closely the eruption of scarlatina, but
confined mainly to the face, neck, and the flexor
ispects of the limbs, and piecoded by a sensa-
tion of local heat and irritation. Desquamation
to a slight degree follows as a rule. In rarer
cases the eiythcma is moic macular, and the
resulting r.ish moibillifoini in ehaiacter Sus-
pension of the drug is the cure It has been
pointed out, however, that these cases, in which
bhe administration of morphin has been followed
by skin etuptions, show undei all conditions a
degiee of marked susceptibility to the other
influences ot the alkaloid
Quinine, 01 other pieparations derived from
cinchona bark, may give rise to eruptions either
by extcr nal contact or by mgestion The foi mci
maybe typically aeon among workers in quinine
factories, and is usually confined to those parts
which, eithei by exposiue, 01 by the natural
occunence of folds oi creases, otter the greatest
facilities for the prolonued or continuous action
oi the uritant These aie, for example, the
hands, w lists, flexures ot joints, mnei surfaces
of thighs, and the genitals The ei upturn is
usually eczcmatous in character, and may be
papulai, vesicular, or pustulai , while in
aggravated cases pcmphigoid foims are met
with, associated with the foimation oi extensive
scales and crusts which leave frequently on
sepaiation icd and oedema to us or oox nig surfaces
Removal of the imtant and the local application
of calammc 01 suhacctatc of lead lotion, with
the addition of liquoi cat boms detergens (."Juw
ad 5 v ), rapidly allay the disc omfoit and promote
the cine It has been observed, however, that
no immunity is acquired by exposure, and the
individual is always liable to a recurrence on
resumption of the offending occupation
The eruptions following the internal adminis-
tration of quinine aie essentially polymorphous,
varying from the most elementary to the most
complicated forms of cutaneous lesion Thus
erythematous, urticarial, papular and vehicular,
pete dual, bullous, and gangrenous forms have
been descnbed (Moirow) In the large majority
of cases -almost two-thirds — the rash is scaila-
tinifoini, and hence its clinical significance It
is of a bright, vivid redness, completely dis-
appeanng on pressure, and showing itself fust
in the face and neck, but rapidly becoming
generalised ovei the whole surface of the bcxly
There is generally considerable, and sometimes
severe, congestion of the mucous covering of
the palate and fauces, and when the onset
of the ei upturn is associated with high fever
(as in a fcwr recorded cases), and followed by
a desquamatiori lasting from a few days to
several weeks, the mimicry is complete, and
the diagnosis from scarlatina is a matter of
great difficulty and doubt for prophylactic
reasons The absence of high fever, as a rule,
and of precedent gastric disturbances is generally
conclusive, but the demonstration of quinine in
DRUG ERUPTIONS
431
the urine is in many cases the ultimate and
only absolute test (vide "Unne") Stoppage
of the drug effects a rapid cure
Salicylic Actd and tialtcylatrv — The cutaneous
lesions pioduccd by the external use of salicylic
acid as an antiseptic have long been familiar to
surgeons, and assume generally the foim of a
vesicular erythema whi<h is always limited In
the aiea with which the agent is biought into
contact Moie variable results follo\v its m-
tenial admmistiation, oithoi as the acid m as
the sodium salt, and erythcrnatous, veuculai,
urtieanal, and hannoirhagic varieties have been
lecoidod The erythematous is tho commonest
form, and may be eithei localised 01 genci«il
It is frequently associated with cedcma, especi-
ally affecting the face (eyelids and lips) ami the
extremities, a ccitam amount of pei spn atmn,
and frequently a rise of tempciatuie, — mani-
festations which bent a stukmg rosemblamo
tD those pioduccd by antipyim, belladonna, and
chloral, and piobably associated with a similai
causation, vaso-motor distui banco No special
clinical impoitance is attached to it, duel the
stoppage of the ding imanably puts an end
to the associated cutaneous phenomena The
presence of the acid is easily iccognised in the
urine by the ferric chloride test
tiulpltonttli m doses vaiymg from seven ami
a half to Unity giams (0 5-2 0 gims ), has been
followed by a blight eiythomatous and scaila-
timfoim ei upturn attended with mtcnso itclunu,
occulting chiefly on the thoiax, shoulders, and
thighs, and followed, aftci its subsidence in a
few d.iys, by slight desquamation It is of no
special mipoit
7ti», and its derivative CaiMa (tad, pioducc,
by dnect contact with the skin, certain lesions
which may \aiy iiom a simple ecvemalous ciup-
tion in the wcakci forms to complete distinction
of tissue by the stronger, as by the application
ot pine carbolic .uul KxtcrualK, continuous
irritation with tar, such as ocouis in gas woiks,
produces the so-called "tar acne,'' which is
caused by the plugmng ot the entires of the
pilo-sebaccous follicles dining contact \\ith the
material, and the fotziiation subsequently of
papules or nodules as the lesult of the in-
flammatory changes in the fibrous tissue sui-
roundmg tho duct These nodules may bicak
down and ulcerate, the piocess being associated
with increased epithelial activity which in time
may tiansgress the bounds and become malig-
nant, developing into what is known as " lai
cancel " (epithehoma) Though doubt has been
thiown on this occmronce, too many cases have
been recorded to leave any room for doubt as
to its reality , and several have come undci the
writer's personal observation In tho eailici
days of Listci's inoist catholic dressings it was
almost the rule, lathei than the exception, to
see a localised vesicular eczema pioducnd in and
about the area protected under the waterproof
coveting Similai effects ha\e been observed
to follow the injection of caibohsed fluids into
mucous and serous cavities In othei cases
eiythcmatous and cczcmatous outbieaks have
followed the absorption of the drug AVhen
poisoning in model ate degree occurs from absorp-
tion, the mine becomes of a daik olive-greenish
(oloni on standing, and the presence of taibohc
acid can be demonstiated by appiopriate tests
Tieatment, of course, consists in iemov.il of the
cause When symptoms of general intoxication
aie acute1, diuretics and huge doses of sulphate
of soda should be given inter nally, and acti\e
moasuies taken to ( on i bat tho associated collapse
f tenet af Punciple* ot Tnattnent. — Hut little
triuajiis to bo added to what has been incident-
ally MR! abo\e as to the mam indication in
tioatmont — It is, in all cases, stop the drug
or dimmish the dose Many patients who
c innot b<Hi a drug in one foim will take it
readily m another, and heie ag.un nothing but
caieful obsoi \ation and icpeatcd tnal can help
tho practitionci \s a general nilo, it may be
laid down that nil I/?M</S ImMe tojiinfutt tone
ti uption* should never be i/men in it (oncunftfited
twin, out tdway* in, the iwunniim ilet/jee, of
dilution In this way \\o know \\o ,110 no.ucst
to the bordoi of safety As to tho so-called
" pieventivo " additions — c i/ aisenn and am-
monia to bionndes and iodides, hyhobiomic
add to quinine, etc — opinions will alwa}s differ,
and indmdual experience will lead to perfectly
sound but \ory dnoigont opinions Above all,
t/te point of importance is to iccouni.se the i ela-
tion between a gi>en dnig and a known erup-
tion , ,md thai being acquuod, tieatmontiosolves
itself into tho alphabet of therapeutics
AVIITOMN UA,SIII«S
Uauvttion -In a veiy large ])orcenUge (20
to 4") poi cent) of easoh tioatod with untitovin,
i ashes are apt to ocxui at a \anahlc pcnod after
tho injection Tho antitoxic pi UK iple cm]>loyed
has nothing to do with their causation, noi aie
thov due to any antiseptic nthuh may ho used
m the piosoivation of the scrum They depend
cntiiely on tho seium itself, as is pio\ed by the
f.ict that noimal hoi so serum prcxluccs them
They appeal less fioquently with tho coneon-
tratcd propaiations now in \ogue than they
used to do when tho injection of largo amounts
of a dilute antitoxin \\as common They aie
also less likely to follow tho administration of
one Luge dose than they aro the injection of
He\cial successive and compaiatnely small doses
Ot<unenee atut Dinatwn -The rash may
occur any time between the first and twenty-
fourth day after the injection A scries of cases
treated with small doses of diiiite antitoxins in
tho Edinburgh City Hospital gave an average
occm lence at about the twelfth day More
recently, however, the concentrated prepara-
tions now in use ha\e appeared to cause an
432
DRUG ERUPTIONS
earlier appeaiance of the eruption, and rashes on
the third, fourth, and fafth days are very common
The raah iray last from <i few hours to alxmt
a fortnight As a rule, howexer, its duration
is not more than fne days, and many disappoai
on the second, thud, 01 fourth day
In certain instances, probably \v heii the blood
of t\\o or 11101 e horses has been mixed in pre-
paring the antitoxin, successne rashes, difieient
in character, may appeal at different dates
Charactrt — Gcneially speaking, the chaiaeter
of the rashes is "septic," th.it is to say, they
aio of that kind which wo are accustomed to
associate with blood - poisoning from \arious
causes They are ah\a}s eiythematow, and
occabionally may be clashed as true utticatia
The commonest foim is that of an eiythenui
multtjormc, a bright pink eruption, macular 01
papulai in chaiaeter, \\ith a tendency in many
instances to circmate arrangement, and often
showing an eccentric extension of the mdn idual
inaculi-s 01 pipules Its distribution is vciy
variable, as it may appear on any pait of the
body 01 face, usually being most intukcd in
the neighlwuihood of the larger joints and at
the seat of injection It also appeals to have
a certain piefeiencc foi the cxteusoi surfaces
Occasionally it may be morbillifoi m 01 scarla-
tnnform in chtuacter, but neither of these forms
is vciy common. In many eases it is exceed-
ingly itchy, and it is this characteiistw which
is most distressing to the patient, \v ho others isc
often feels quite well When the eiuptiou is
utticarutf it is marked by the usual w heals
charactenstic ot that condition, and those fre-
quently occur on the face
Other symptoms — AD regards pyiexin some
cases show no fc\er at all, and others only blight
deviation fiom the normal On the other hand,
in young clnldien especially, theic may be a
considerable use, the chart showing tempera-
tures of 101° to 103° even when tlii'ie is no
complicating arthritis.
GKJenia is not uncommon, and in some in-
stances may involve considerable areas of skin,
though more frequently it is limited to the
hands and feet
Arthritic is a very common complication, and
indeed may occur without a lash at all The
joints of the extiemities are most frequently
complained of, and may be swollen and tender
Diagno*\\ — There is not usually any difficulty
in diagnosing the rash It is to be looked for
m a large pioportion of cases injected, and
therefore its occurrence need cause no surprise
Occasionally, however, when scarlatimform or
morbilhform in character it may cause anxiety
The marked itchmcss of the serum rash, the
absence of catarfhal symptoms (in its measly
form), and of those of the usual invasion of
scarlatina, should decide the case
Treatment — The rashes scarcely require any
treatment, and their presence has little or no
clinical significance. To relieve the itching,
lowcver, tepid sponges or the application of a
ead lotion may be found useful For the
arthritis, salol and the sahcylates often appear
to give ichef Some prefer a palliative treat-
ment, with laudanum fomentations and opium
internally The exceedingly variable duration
of unticatcd cases makes it almost impossible
to judge the efhcacy of any treatment
The followmg Plates will be found useful for
reference —
Argyna — Crocker's Allan, PI xxxun
Arsenu — 0«mcer, Arch <tf tiury PI \x
„ Keratosis, „ PI xvm
„ Psoriasis, „ PI xi\
Bionude — Confluent form, „ PI x\\v
„ Ulccrativo, Syd Soc Atl PI xhv
Bullous, III AM New, Jan 1889
Chloral— Erythema, Arch of SM</ PI v
Clnysarobin— Krythema, Crocker, PI \xxvm
[odide — Bullous, „ PI \xxvi
/Tuberous, At eh. ot $wg PI in , iv
" \ (fatal case)
JPuipunc, III Med A~ew«, Nov 1888
" \ (Mackon/ie's case)
„ Bullous., Syd Soc Atl PI xxxin
Drug HabltS. See ABSINTUIBM , ALCO-
HOLISM, ANESTHETICS , ARSENIC, CANNABIS
INDICA , CHLORAL, CHLOROFORM, COCAINE,
KTH&.R , HYPNOTICS, HYPNOTISM (U*e») , MOR-
PHINOMANIA AND ALLIED DRUG IlABl'lS (Antl-
pytirii Antifelirin, Pataldehyde^ CMoiodyne, etc ),
SULPHONAL, TRIONAL, VERONAL, VICE (Drug
Habit* and XmoKmg)
Drummond - Morlson Opera-
tion- — An operative method of treating ascitcs
mtioduced into use by Di David Drummond
and Mr Rutherfoid Monson m 1896, its object
is to develop vascular anastomoses between the
portal and systemic venous systems As per-
formed by Drummond and Morisou, the abdo-
men was opened and dned out \Mth sponges,
the parietal peritoneum and that covering the
liver and spleen A\ere sciubbcd with a sponge;
the omentum \vas sutured across the anterior
wall, and a tube was loft in the pouch of
Douglas The ascitcs was cured, and Talma
and Schiassi and others have since obtained
equally satisfactory results by means of the same
or slightly modified methods, so that, in 1905,,
Bungo was able to collect 274 cases from litera-
ture (including 14 of his own) in \shich the
operation had been performed The indication
for the procedure is portal obstruction from
hepatic cirrhosis, but it is applicable in portal
obstruction due to any cause , the most marked
benefit following it is relief of the ascites, but
hfemorrhages from mucous membranes (eg.
htematemesis) may also bo greatly benefited,
DRUNKENNESS
433
m about 30 per cent of the recorded
ascitea was relieved
the
See ALCOHOLISM.
See LABOUR, FAULTS ris
Drunken n
Dry Labour.
THE PASSENGER (Early Escape of Liquor Amnii,
Dty Labour).
Dry Mouth. See SALIVARY GLANDH,
DISORDERS OF (Xerostomia)
Dry Rot* — Timber (e <y in the construction
of a house) winch is subject to alternate j
wetting and diying, or \\hich is imperfectly
ventilated, decays, it is affected cither by \\ct
or by dry rot (Meruleus lachi ymans), diseases
due to the gro\vth of the mycelium of fungi
and in which the wood is minced to a powdei ,
such wood must be entnely removed if the
process is to bo stopped , preventives are found
in thoiough ventilation of beams and joists, by
painting and vai lushing, and by ioiung creosote
into the wood under piessure (Bcthell's process)
Dual Personality. See MEMORY IN
HEAL j n AND DISKASK (Periodic Complete Loss
of Memmy) , DOUBLE CONSCIOUSNESS, UNCON-
Dubinins Disease. See CHOREA
(Electoral GYiomr) , SPASM (Vat letie*, Paramyo-
clonw Multiplex, Diaynow)
DubolSlne. — An alkaloid, probably
identical with hyoscyamme (C17H21NO4H2O) ,
it is obtained fiom the leaves ot Duboisia myo-
poroides, and is found in Datura tStranwmv.ni
and Hyoscyamvs niijti , it resembles atropme in
its action, e g it is a mydnatic, but its effects
as such are more quickly pi od need and more
evanescent , its toxic effects also differ from
those of atropim* It has been used as a
mydnatic (as ophthalmic discs containing ^^
grain), and m exophthalmic goitre See ALKA-
LOIDS, TOXICOLOGY (Alkaloid*, Henbane and
Stramonium)
Duehen ne - Erb Paralysis. — A
type of paralysis in which the deltoid, biceps,
brachialis anticus, and supmator longus are
affected See TRADES, DANGEROUS (Lead-Pmwn-
tng), BRACHIAL PLEXUS, SURGICAL AFFECTIONS
OF.
Ducrey'S BaclllUS.— Duciey's bacillus
of soft sore, a micro-organism causing acute
suppuration See SUPPURATION (Etiology) ,
VENEREAL DISEASE (Soft Sore or Chancroid)
Duct Or DuCtuS.— A canal, usually
serving the purpose of conveying the secretion
away from a gland, sometimes acting as a
communication between one blood-vessel and
another Instances of the former are found in
the MIe- ducts, the cystic duct, Barthohn's,
Gcvrtnrfs, Muller'B, Wharton's, Stcwon's, and
Wtrsung's duct ; and of the latter in the ductus
artenosuB, the duetto venotu*, the thoraci^ duet,
and the ducts of Cuvter
Ductless Glands. See PHYSIOLOGY,
INTERNAL SECRETIONS (Suprarenal Bodies, Pitui-
tary, Thyroid, Ovat ies, Thyinu*, etc )
Ductus ArterlOSUS. See HEAHP,
PHYSIOLOGY OF (Embryology), HEART, CON-
GENITAL MALFORMAI'IONH OF (Patent Ductus
Artewow) , PiiYsioix)GY, REPRODUCTION (Fatal
Circulation)
Ductus Venosus. See HEART, Pmsio-
LOGY (Emfayoloyy) , PilYhlOl Od\, REPRODUCTION
(Fatal Cinulation)
Duga'S Test.— A test for dislocation of
the shouldoi , if, \vhen the hand of the dislocated
side is placed on the oppos'te shoulder, the
elbow is elevated and stands out prominently
m front of the chest, there is ically a disloca-
tion See SiiouiDhR, DISIAMS AND INJURIES OF
(Dislocation*, Sif/nt and Hi/ in plow*)
Duh ring's Disease. See DERMATITIS
HERPRIIIOUMIS
Duhrssen's Operation.— A method
of vaginal fixation of the uterus in cases of
obstinate retioversion
Dulcamara.— The branches of Solanum
dulcamaia (Hitteisueet 01 Wocnly Nightshade),
containing t\vo alkaloids (solanme and dulca-
marine, C22II,4O10), used as an alterative m
somo skin diseases, in eh ionic rheumatism, m
whooping-cough, etc , not now official in the
British Phaimacopouia
Dulcite. — A pohb>dnc (hexahydnc)
alcohol, isomciic with mannite (C0H14Ofl or
ChII8(OH)0) , it is user* to s \\eeten the food in
the tieatment of diabetes
Du I ness. See FT EUJIA, DISEASES OF (Amte
Pleurisy, 81 gn* of Pleural Effu^on, Percussion),
AiiDOMBv, CLINICAL INVFSIHJATION OF (Pev-
cuwori) , CHEST, CLINICAL INVESTIGATION OF
(Percussion) , etc
Dumb Atflie. — Masked intermittent
fever, masked malana
Dumbness. See DEAMIUHSM, CRETIN-
ISM, HYPNOTISM (Psychical Dumbnetn) , MENTAL
DEFICIENCY, etc
Dum-Dum Fever.— Piroplasmosis, or
kala-azai, 01 tropical splenomegaly, a chronic
disease of India, China, Kgypt, and the Tropics,
in which the spleen and liver are enlarged, there
are haemorrhages and transitory oodemas, a
moderate degree of anaemia," and irregularly
remittent fever , a protozoon parasite (Donovan-
Leishman bodies) has been found m the spleen ;
quinine is useful, but has not the same good
effect as in malaria.
28
434
DUODENITIS
Duodenitis. — Inflammation of the duo-
lenurn (?.v.).
DuOdenO-. — In compound words duodeno-
means relating to the duodenum e.g duodeno-
tomy is the operation of cutting into the
duodenum, duodenostomy is that of making a
permanent opening into the duodenum through
the abdominal wall , duodeno-entet ostomy is that
of making a permanent communication between
the duodenum and another part of the intestine ,
and duodenoc/toleiystostomy is that of making a
permanent communication between the duo-
denum and the gall-bladdei
Duodenum. See aho ABDOMEN, IN-
JURIED OF (Lemon* of Intestine), APPENDICITIS
(Drttf/notti Jrotn Duodenal Ulcet), BURNS AND
SCALDS (Intestinal Conciliations, Ulcer of
Duodenum) , HXMAIEMESIH (Causes and Source) ,
INTESTINES, DISEASES OP (Malformation* of t/te
DiHxIenuni) , INTESHSEH, DIHEAKLS OK (Ufcei s of
the Duodenum) , INTFSTINES, DISEASES OF (Mahy-
nant Disease), LIVER, DISEASES OF (Aneurysm
of Ihpatic Artery, Diayno*is) , MEL.TNA (Cause*,
Duvdenaf Ulcti), PERITONITIS, ACUTE GKNMIAL
(Etwloyy, Perforation of Duodenal Ulcet) ,
I'liYuioixxn, FOOD AND DnimnuN (Ahmcntaty
Canal, Duodenum), POST - MuRi'BM METHODS
(Kid nn nation of the Body-Cawtie*) , SIOMACH
AND DUODENUM, DISEASES OK (Anatomy, Diges-
tion, Disease*, Mot bid Anatomy, Ulcet, etc),
STOMACH, SUROICAIJ AKPKCIIONS (Complication*
of Gait nc View) — Affections ot the duodenum
are of gieat interest both from a medical and
surgical stand-point But, as the gieat majonty
of diseases which involve the duodenum cannot
be clearly diffcientiated clinically from those of
the pyloric end of the stomach and the small
intestine, these will be descnbed in other
articles The object here is to present a buef
epitome of the \anous disoidcis
There .11 e ceitain points of anatomical and
physiological impoitanee, the position, the
horse-shoe shape, the close connection with the
head of the pancreas, and the entrance of the
common bile duct, arc all of gicat clinical un-
importance
With regard to ]>osition this may be slightly
modified by alterations in the position of the
stomach and intestine (vide " Enteroptosis ")
Short of cnteroptosis, however, a careful ex-
amination of post-mortem cases made at random
readily reveals greater variations in the position
of the abdominal visccia than is usually thought
of during life
The close relationship between the receptive
and motor mechanism of the duodenum and the
stomach, and also the influence of its secretion,
is fully considered in the article "Digestion
and Metabolism "
The most striking and obvious perversion
of this mechanism is seen in the familiar class
of case known as bilious vomiting, where, as a
result of combined motor hyperactivity and
relaxation of the pyloric orifice, the vomiting of
bile is brought about Apart from this obvious
derangement, it is likely that there are many
other perversions of function that are not so
leadily nor so definitely represented by definite
outward symptoms Thus it is impossible to
believe that in many cases of dyspepsia the
function of the duodenum is not very definitely
interfered with We are led to this opinion by,
among other things, the close relationship that
obtains between the motor acti\ity of the
muscle of the duodenum and that of the
stomach and intestine In the absence of
obvious changes in the fceccs, we 'are perhaps
not fully justified in making a diagnosis of
duodenal dyspepsvi, but it is not unlikely that
some cases of dyspepsia, \\heic the various
sensoiy symptoms dcM'lop several hours after
the ingcstion of food, associated it may be \vith
the presence of pain on piessmc to the right of
the middle line in the right hypochondriac
legion, «wo really cases where the sccietory
01 sensori-motoi mechanism of the duodenum
is pumaril^ .it fault
A simple ulcet is met \vith here \\hich may
piesent all the clinical features ot, and be
clinically indistinguishable fiom, gastiic ulcer.
The ideas foimeily entei tamed regarding the
i^ieat frequency of ulccration of the duodenum
as a sequel of burns have been modified some-
what during the last few years, merely as a
lenult of more caieful investigation into the
truth of the old text -book statements (*ee
" Bums ")
Simple nlceiation may develop us a icsult of
nutation fiom a large gall-stone
Malignant Dnease — This is by far the most
important lesion, and specially in Mew of the
possibility of beneficial results following early
opciative interference As it is impossible
clinically to differentiate between a primary
inoibid growth of the duodenum and one in-
volving the head of the pancreas 01 pylorus,
this condition will be described more appropri-
ately in the section on these viscera It is
sufficient to indicate hoic the gieat importance
of a thorough examination of the faeces as a
diagnostic factor in such cases The absence of
bilo in the stools suggests some obstruction to
the oxcietion of bile piobably involving the
onfice of the duct, the presence of undigested
fat in the faeces, and occasionally the presence
of glycosuna, w ou)d rather point to the pancreas
as the primary focus of disease
Inflammations — These are of no great clinical
significance in themselves , they may be second-
ary to gastric catarih, or merely a local mani-
festation of the general enteritis present. If
severe, jaundice may develop, this, however,
usually signifies an extension of the catarrhal
process to the bile-ducts (see " Gall-Bladder and
Bile-Ducts").
DUPUYTREN'S CONTRACTION
435
Dupuytren's Contraction. See
DEFORMITIES (Hand and Finyers, Congenital
Contraction, Diagnosis) , FASCIA (Contraction of
the Palmar Fascia), GOUT (Mot bid Anatomy,
Prate of Soda in Tendon Sheath*}.
Dupuytren's Fracture. ^ANKLE-
JOINT, REGION' OF, INJURIES (Fractutes m tfie
Vicinity of)
Dura Mater.— The outer membrane,
strong and fibious ((/via), which covers the
brain and spinal coid (cerebral and spinal dura)
See INSANITY, PAIHOUKJY 01 (Pathulot/tcal
Anatomy, Dura Afater) , M EVINCES OF THE
CEREBRUM (Anatomy, Vaicttlai Disturbances,
Inflammations, Tiunoiii <, etc ).
Durande's Mixture.— A mixtuic of
ether and turpentimc given in the hope of
dissolving gall-stones
Dliret'S Balsam.— An antiseptic oint I
meut (baume Dmet), said to contain coal-tai, I
oil of cado, resoicm, menthol, gtiaiacol, camphor, !
siilphm, boiav, glyctMino, acetone, castoi oil, I
and wood oil , it is, thercfoie, a very complex |
piepaiation, containing nine antiseptics, some of I
which arc also mild cutaneous stimulants (vide \
Lancet, Juno 10, 1906) !
DiirOZiez'S Sign.— Tho double muunur
which can sometimes lu» pioduced by pressuic
on one of the Lugo .utenes (e 7 the carotid) in
cases of aoitic incompetence
Dust Diseases.— Diseases \luc to the
inhalation • ol particles of dusst (pneumono-
konioses), such as coal dust (antht acosis), metallic
(steel) dust (uderosis), and stone dust (chakcosis) ,
tuberculosis and typhoid fever may be upload
also by infected dust particles See LUNGS,
PNEUMONOKOMOSIS , TUBERCULOSIS (Poitals of
Invasion and Chtinneh of Spread), TYPHOID
FEVEU (Etwloqy)
DuttOn'S Disease. —Human tiypano-
somiasis See PARASITES (Protozoa)
Dwarfism. See aho ETHNOLOGY (Dwarf
Races), ATROPHY, H\PKRTUOPIIY, ACTION I>RO-
PLASIA; LABOUR, PROLONGED (Pel we Deformities) ,
MICROSOWA t etc — The word "dwarf," a veiy
old term, has in its progress down the centimes
lost much of its significance and of the sharpness
of definition which it may once have h.ul It
now signifies simply a diminutive adult human
being, and includes cases of stunted stature due
to postnatal diseases of the spine and lower limbs
(rickets, etc ), as well as to antenatal maladies
(achondroplasia) and to teratological states
"True dwarfism" is an expression which has
been introduced in order to define more exactly
the conditions which alone ought to bo em-
braced under the name a true dwarf is a person
of unusually small stature, not the result of any
particular disease or defoimity, but merely fiom
growth having fallen much short of the usual
standard In this icstnuted sense the word
dwaifism is practically synonymous with micro-
somia , and in this article it is true dwarfism or
microsomia that is being considered
True dwaifisni or microsomia — a teratological
smallness of all the parts — may bo antenatal or
postnatal in origin There is, for instance,
embryonic microsomia Sometimes when we
are engaged in examining an abortion sac we
find to our surprise that it contains an embryo
of a size much smaller than the size of the sac
h.ul led us to expect Yet this embryo may
show a device of development in accordance, not
with its si/e, but with that of the sac containing
it and \\ ith the estimated age of the pregnancy
Tt may, thciefoic, be regarded as a "dwarf
ombiyo," or H case of " embryonic microsomia ",
although it has, pel haps, been customary to
look upon it as an example of oarly hydrammos
01 embryonic hydiammos Dm ing f octal life,
also, dwarfism may show itself (fatal mtcimomia)
When, for instance, a fcctus is bom .it the full
term, h«u mg a weight of loss than 3 Ibs and a
length of less than 12 inches, but possessing the
nthei si«<ns of maturity (fiiigei -nails projecting,
absence of lanugo, etc ), it is to be i egarded as
a case of foetal mi< rosomia or foetal dwarfism
In Sir KvprAid Home's case, a female child
weighing 1 Ib and measuring 7 inches was born
at the full term (the mother had had a fright
when thieo months pregnant) , the child, known
as the "Sicilian dwarf," died at the age of nine
yoais, when she was ncaily 20 inches in height,
and had the ossification, dentition, and mental
powers of a child of two rather than of nine years
There was, thercloio, an ariest of both growth
and postnatal development here, and to this
combm ition it has been proposed by Hastings
Gilford to give the name of " ateleiosis " Other
instances of foetal mici owimia were those of
Nicholas Feny 01 " BeW " (weight at birth less
than 1 Ib, length 8 inches), "Vnncess Paulina"
(12 inches in length when born), the "Marquis
Woljjja" (9 inches in length at bath and less
than 2 Ibs in weight), etc
Dwaifism, howcvci, is by no means constantly
present at birth the retardation of growth may
bei*m at one, two, thiee, or four years of age ,
indeed it may not commence until early adoles-
cence Joffeiy Hudson, foi instance, was not
a congenital dwarf, and his parents were of
average height, yet at the age of nine years
he was only 18 inches high He had some
chequered experiences in an adventurous life
he was presented " m a pie " t$ King Charles I ;
he fought a successful duel, for, as a writer says
describing him, " although a dwarf, Jeffery was
no dastard " , and ho was sold as a slave in
Barbary This last and most trying adventure
had a special mteiest, for it caused, or at least
436
DWARFISM
preceded) the recommencement of growth at the
age of thirty years. Joseph Boruwlaski was
born in Polish Galicia m 1739, and he died at
Durham m 1837, at the great age of ninety-
eight; he was never more than 39 inches m
height, and ho had a sister who measured
2 feet 4 inches, a brother who measured 41
inches, and another brother whose height was
6 feet 4 inches This association of miero-
somia with maciosomia in the same family
history is not uncommon Some dwarfs have
been above the average bizo at birth , this was
the case with the famous "General Tom Thumb "
In an observation reported by Claudei each
alternate child m a family of eight was a
dwarf.
Many causes of microHomu have been alleged,
among which may bo named poor 01 bad food,
the infectious fevers, mjiuies (especially of the
head), chionic hydiocephalus, idiocy, foetal
nckots, alcoholism of the patents, and consan-
gumity 01 advanced age of the parents Of
course, if an antenatal cause be admitted, it
must bo supposed to lemam latent for some
time in the cases in which th'» ch\arf.bin docs
not appear until later childhood
Anomalies in development (malform.itionn)
are not uncommonly associated with (Uarfisin I
Thus, dentition may be incomplete 01 letarded ,
the general ossification of the skeleton may be
taidy , the skm may be hanlevs and the fingeiti
almost naillcss , the icpioductrve oigans may be
defective, as shown by stenlity and want of
sexual instinct in both sexes, by cryptoichidy in
the male, and by absence of pubic hair and
delayed inoustiuation 01 oligomenorrhcca m the
female , and the mental powers may bo of a low
order, pointing to incomplete development of the
higher nerve centies Of course, exceptions to
all these statements exist some dwarfs, for
instance, have been perfectly well foinied , some
have been able to have childien, generally of
normal si/e, some have lived to a good age,
and some have had fair intellectual powers It
is evident, therefore, that the two processes
which are going on side by side in antenatal
life as well as in infancy (I refer to development
and growth) do not nccessanly fail together or
succeed together In other words, an infant
may grow to its proper size although it is mal-
formed or defective, and a child may be perfectly
formed but a dwaif in size. At the same time
it is not uncommon to note that both growth
and development have suffered, and that the
child that is stunted m size shows also defects
m development (malformations) and m functional
activity. A possible explanation of these
irregularities m#y be found in the date when
the arresting cause (whatever it may be) comes
into action , for if it be effective m antenatal life
it will more probably affect both development
(which is then active) and growth, whereas if it
only begin to show itself m childhood (when the
greatest number of the developmental processes
are completed) it will delay or stop growth
alone. What this arresting cause is has not yet
been discovered , but it may be one or many,
and it may be the same or (more likely) different
for the different epochs of life (embryonic,
footal, infantile, adolescent). Possibly an in-
ternal secretion may be the root -cause of
dwarfism , perhaps the thymus, the thyroid, the
ovaries and testicles, and the pituitary body
may all at one time or another in life preside
over the processes of growth.
Dwellings.— In sanitary law a dwelling-
house means "any inhabited building, and
includes any yard, gaiden, out -houses, and
appurtenances belonging thereto, or usually
enjoyed thciewith, and includes the site of
the dwelling-house so defined" (llounnq of t/ie
WorLiny Claws Act, 1890) See CELLARS;
CURTILAGE , DISINFECTION , SEWAGE AAD DRAIN-
AGE , VEVTILAJION AND WARMING , etc
Dyad* — A bivalent element (eg calcium)
01 iodide (ey bO4) m chemical nomenclature
Dyaster Stage. >SW PHYSIOLOGY, THE
CELL (
Dying Declaration. »v«» MLDICINE,
FORENSIC (Dying Declarations)
Dymal. — A non-nntatmg, antiseptic dust-
mg-powdei , didyimum salicylate
Dynamite. SeeNirno(-,L\CEm\h — Dyna-
mite is a mixture ot nitroglyceiine (7.") per cent)
and an miusoiial earth or kiesulguhi (25 per
cent) , the Litter serves us an inert base, being
composed chiefly of the fossil icmamiof diatoms.
Another foim of dynamite is that in which the
nitroglycerine is combined with a combustible
or explosive base, such as gun-cotton or
potassium nitrate Roth the explosion and
burning of dynamite give rise to obnoxious
fumes which may cause poisoning , it also
causes toxicological effects if swallowed See
TRADES, DANGEROUS (Rids attending the Manu-
facture and Use of ™ '
Dynamometer. — An instrument for
measuring the power of muscular contractions,
especially the strength of a hand -grasp, by
moans of it a difference m the power of tho
muscles of the opposite sides of the body can be
detected, eg. in hemiplegia
Dyne. — The absolute unit of force in
dynamics , defined as the force which, acting on
a moss of one gramme, will propel it with a
velocity of one centimetre m ono second.
' Dys-. — In compound words dys- (Gr. &W-,
meaning bad, ill, or hard) "destroys the good
sense of the word or increases its bad sense " ;
thus dysarthrw means defective articulation m
speaking, dysarthrosis means a defective or dis-
located joint, dysbului means morbid impair-
DYS-
437
ment of the will, dyscholia means a morbid
condition of the bile, dyscona moans an irregu-
lar shape of the pupil, dysemesis means difficult
vomiting, etc. etc
DysaCUftlS.— When an unpleasant sensa-
tion is caused by ordinary sounds (e g headache)
it has been termed dysacusis
DySSBSthesla.— A moibid or Diverted
sensation (tingling, foimication, tinnitus, etc.),
or an impairment of sensibility, panesthesia ,
the pamf ulncss of a sensation which normal!} is
accompanied by no pain. See HYSTERIA (iten-
wry Disordos)
DysanaffflOSla. — Inability to read
correctly fiom loss of power of understanding
written signs , alevia 01 dyslexia , word-blind-
ness
Dysbasia Angio-Sclerotlca of
Erb. — Intermittent lameness or claudication
(q.v ), or Walton's crural angina , it is found in
cases of aueuiysm <>f the iliac artery and in
arteno sclerosis , and it is due to diminution in
the supply of blood to the muscles
DySCheziO. -Pain 01 difhculty dining
defalcation >SV LABOUR, INJURIES TO THE
GhNBRATi\E ORGANS (Evidence of Injiirm to the
Pelvic Aiticulations, Sact o-Coccyyeaf Joint)
DySChrOIYiatOpSl a.— Incomplete col-
.r- blindness en diminished colour-sense See
( Consent tal Colour - Jiltndne* s,
our
COLOUR Visiov
Varieties)
Dyscinesfa. —Diminished 01 mipaned
power of vtoluntaiy imneuieiit Uteiine dys-
ciuesia is the name \\hich has been given to
pain produced by talking and other ordinal y
niovcmenth, and referiod to the uteius (Graily
Hewitt).
DySCrasia. — A iaulty state ot the con-
stitution or of the blood (as the result of such a
disease as cancel) , the \\oid liteially meant) an
abnormal or bad mrvtuie (from Gr SIKT-, and
K/Micri?, a mixture) , cachexia, the Juenion fiaytc
dyscrasia is haemophilia, the unc acid dyscrasia
is the unc acid diathesis, dyscrasia satumina is
lead cachoxia, etc
DySdlachoresiS.— Constipation (fi om
Gr Sucr-, haid, and 8iax<apeiv, to pass through)
Dysentery.
DEFINITION . 437
BACTERIOLOGY 437
ETIOTXMSY —
General Conditions . 440
Personal Conditions 442
PATHOLOGICAL ANATOMY —
Non-Amoebw Form . 442
Amoebic Fotm . . 443
Associated Pathology 443
SYMPTOM
Non-Amoebic Dysentery
Amoebic Dysenteiy
Chronic Dysentery
orECiAL FORMS AND COMPLICATION b
DIAGNOSIS
PROGNOSIS
PROPHYLAXIS
TRK MOMENT —
In Acute Cases
In Chtomc Cases
444
415
443
446
447
447
447
448
450
See o/60 COLOV, DISEASES OF (Simple Colitis,
iaf/wv*) , ENEMATA (Diarrhea and Dysen-
tery), FBCEh (in Dyw ntery) , LI.BR (Acute
Hfpat.ti^tt LIVER (Abicen, Tropical), LiVKn
(Portal Tfo outflow), LUNGS, ABfeCBSS OP (Amoe-
bic Uf/nentety), MALARIA (Dyttentetic Form),
NBRVPS, MULTIPLE PURIPJIEUAL NKUBITIS
(Caw*) t TYPHOID FEVER (tief/uela>) , WATER
(Ihteav* j/rodwed by Contaminateil Water)
S\NON\MS Gr AixrevTfpia , L Tormina, E.
The Bloody Flux , G Ruhr, F Dybcnteiie.
DEPINIIION -Dyscntciy is a clinical term
connoting a complex of symptoms dependent
on inflammatory, ulcciativc, and gangrenous
lesions of the large mfrbtinc It may be loughly
dchned as a group ot closely allied infective
diseases, charactered by frequent mucous,
bloody, 01 facrouss stools, by giipmg pains
(totuiina), moie or loss straining (tetievnus),
generally with letention of fteceH
]5An PRIOLOOY — In ccitam cases of dysontcrj'
baiteua alone arc met with in the stools and
mtostnul lesions , in othei>, amoeba) as \\r\] as
bactcua aie pie sent The precise significance
of the amojbte in i elation to the dj sen tone
process has not been fully dctci mined, but as
they aic associated \\ith a fonn of the disease
piesentmg distmctne clinical and pathological
charactois, wo aic justihed in admitting a 11011-
amoobic and an amojbic foim of dysentery
The divcisities obsci\ed in the clinical features
and 111 the lesions of non-amoebic dysentery,
taken along with the lesults of bacteriological
icseaichett, indicate that this foim will ulti-
mately be found to comprise t\vo or moie
distinct %anetics
In non-amoebic and ama'bic dyscntciy alike,
the common bactcua of suppuration, btaphylo-
cocci and streptococci, arc met with in the stools,
as, indeed, they frequently are in the stools of
healthy peisons The staphylococci, so far as
is knoun, aie not in any sense specific, but
\\hcn the disease is once established they
doubtless trcai a pirt — perhaps by no means
on mconsideiable one — m promoting suppura-
tion and destruction of tissue The three
varieties of the staphylococcift — aurcus, albns,
and citreus — aic present in the stools, and are
found \vith equal frequency m the epidemic
dysentery of temperate climates and in the
chronic dysentery of tiopical regions Strepto-
438
DYSENTERY
cocci are often very abundant in dysenteric
stools, their multiplication being favoured by
the inflamed condition of the bowel. All
pathogenic micro-organisms vary in virulence,
but none more so than the streptococci, and
experiments show that in some forms of
dysentery, at least, they play an important
part in the dysenteric process The experiments
of Zancaiol and of Celli and Fiocca seem to
place it beyond doubt that dysenteric lebionb
may bo produced by the admimstiation, by
the mouth or rectum, of puie cultuieb of
virulent stioptococci derived from dysentciic
stools While the former pathologist inclines
to regard the btreptococcus as the pimcipal
pathogenic agent in dysentery, Celli and Fiocca
relegate it to a secondary position, but claim
for it the power of exalting the Minlciicc of the
bacterium coh commune (which they look upon
as the ordinary bpecific nrciobe of dysentery)
into that vaiicty which they have named the
bacterium cob dytentencum. Thcbe pathologibtb
have occasionally found in djsontenc btools a
small species of proteus which is also found to in-
tensify the viruljnce of the B coh commune, and
with which they have succeed* rl in somo instances
in producing dysentciic symptoms in amm.ilb
Bertiand and Handier found the R jtywyancu*
in the btoolb both of the epidemic dysentery of
France and those of the chronic dybcnteiy of
warm clumiteb, but more abundantly in the
formei Calmcttc found this oiganibin not
only in the btools of acute dysentciy m Cochin
China, but ,ilho in the ulcerations of the laige
intestines and in the blood He ascribes to it the
preponderating rule in the causation of dysen
teiy, maintaining that it alone of the micro! >es
piescnt in the stools is capable of leproducmg
the lesions of ilysenteiy These statements
have not been confirmed
Anaerobic vibrios iuo met with in a consul el-
able number of cases both of the acute and
chronic disease The inflated condition of th<*
stools is ascribed to the picsencc of these
microbes They are merely occasional and
subsidiary agents
All recent obseners recognise the bacillus
coh commums, or lather a \uulcnt variety of
it, or some closely allied oigamsm, as one of the
mobt important pathogenic agents of dysenteiy
It was one of the microbes constantly met with
by Beitnmd and Bjiuchoi This was piobably
the bacillus found by Chantemesse and Wirlal
in the walls of the intestine and mcscnteiie
glands of one \vho had died of dysentery, ;ind
in the stools of those suffering from the disease
Maggioia found it in large numbers in evciy
case he examined, and he proved expeinnen tally
that it could pioduco dysenteric lesions in
animals It is to the researches of Celli and
Fiocca, however, that we are chiefly indebted
for our knowledge of the part played by this
bacillus m the causation of dysentery. They,
in collaboration with others, have shown that
by itself it is capable of setting up dysentery in
animals whether administered by mouth or
rectum, and that the toxins obtained from pure
cultivations give rise to dysenteric symptoms
and lesions, that the serum of dysenteric
patients causes agglutination of the B. coh
dysentencum This bacillus, although capable
by itself of giving rise to dysentery, ib generally
absociated with streptococci, which exalt its
\irulence within the body and in frccally
polluted soil. Ainaud, according to Schoube,
has also come to the conclusion that this bacillus,
when its virulence has become intensified by
association with other miciobes, 01 in some other
manner, is the specific microbe of dysentery
Quite recently Shiga, voikmg in Kitasato's
Institute in Japan, has isolated and cultivated
a bacillus wh'ch is not found m healthy men or
animals, bat which is ahvays present in dysen-
teric stools, in the lesions of the colon and
rectum, and often in the mescnteiic and rctro-
pcutoneal glutids of those who have died of
dysenteiy, but never in the liver or spleen
He describes it as a shoit bacillus, similai in
moiphological characters to the colon bacillus
He found the cultuies of this microbe to
present the phenomenon of agglutination with
the serum of persons suffering fiom dysentery,
but not with that of healthy persons or of
those buffeting fiom other diseases This
bacillus is believed to be identical with the
B coh dysentoiicum of Celli and Fiocca Theie
is thus a large amount of evidence pointing loa
variety of the B coh commums as one of the
chief agents of epidemic dyseuteiy, and possibly
also of other forms of the disease »
The Johns Hopkins Commission to the
Philippine Islands has su< reeded in isolating a
bacillus that answeis to all the tests applied to
the B coli dysentencum We have met with
no description of its thai act era.
Ogata m 1892 found a shoit bacillus in djsen-
tenc stools, about a quaiter of the length of the
tubercle bacillus, \\hich, when introduced by
mouth or rectum, caused djbuntenc symptoms
m animals Wo have met with no fuithei
accounts of this microbe
It seems evident from these reseaichcs— (a)
that a chief place in the pathogcncsis of dysen-
tery, or of some forms of it, must be assigned
to that variety of the B coh commums known
as the bactciium coh dysentencum , (I) that a
Mnilcnt form of streptococcus and a small
protcus, possibly also other organisms, mo
capable of initiating the dysentenc process,
(c) that bacteria that are themselves po well ess
to give rise to dysentery arc nevertheless active
agents of mischief, somo of them by increasing the
virulence of the specific microbes, others by pio-
moting suppuration and ulccration The types
of dysentery caused by the individual organisms,
or their grouping, have not been determined.
DYSENTERY
439
Amoebic Dysentery. — Amcebee are met with m
the stools of healthy persons and m those
suffering from cholera, enteric fever, and other
inflammatory and ulcerativo diseases of the
bowels. A bimple irritation of the intestinal
canal seems sufficient to lead to their multipli-
cation Schuberg, for example, found amoebic
m the loose stools of ton out of twenty healthy
persons to whom he hud Hdrnimsteud a purga-
tive dose of Cailsbad salts The frequency
with which these oigamsms are present in the
intestinal canal in health diftois gicdtly m
different regions and localities lu borne pirts
of Italy, Greece, and Egypt, amcc-bo? aie common
parasites of healthy poisons Gassci, in Algciin,
examined the stools ot twenty persons m perfect
health and found amoebic in foui of them
Amoebec are moio common in warm than in
colder climates This harmless amoeba coh is
morphologically indistinguishable from the
amoeba met \vith in d}sentei}, which is known
as the A tfyvenfftire Othci specie b of amcch<e,
smaller and less le.idily lecogmscd, such as the
A (juttuln, ollonyn, gjmiow, dta/diund, vcinn-
culnns, and i erf H trim i*, aie also frequently
present in the stools of peibons in health and
of those sufteimg fioin canons intestinal com-
plaints, including d}scntei} Then pathological
effects, if any, aie unkno\\n
The A tlywntt i in is a unit ellulai, cvcentiicall}
nucleated oig.unstn, consisting of «i gianulai
untoplasm and a homogeneous, pale giccn ecto-
plasm It vaiics in diametei tiom 6 to 36 //,
and often contains one 01 moie non-contiactile
vacuolcs It is extiemely motile and loco-
motive, but becomes motionless .it a tempeiatuie
below 75r If Accoidmg to the obseivations ot
Grassi and Calandi net 10, it multiplies by simple
fission in liquid fanes, but when the stools aie
pultaceous the .imu'b.i' become cnc}sted In
this state they contain one 01 moie nudei which
de\elop into amoeba? when ingested Free
amoeba; have been found in water and soil
polluted with dysenteiic evacuations, and it
is pi obubly by dunking watei or contaminated
food that they gain admission into the intestinal
canal These ama'b.u hequcntly contain led
blood coipusclcs and baetena Hence it is
contended by Home th.it by engulfing ami
digesting the baetena ot dysentciy the amu'boj
are to be considered as usctul auxiliaiies to the
phagocytic culls of the intestine Otheis look
upon them as desti active agents, pioclunug
softening, ulceration, and sloughing of the
tissues of the bowel, and as vehicles foi tians-
porting baetena fiom the bowel to the hvei
They are found m the blood-stained mucus
m the minute gelatinous masses of necrotic
tibsue denved fiom the ulceis, and in smallei
numbers in tho liquid stools of amwbic dysen-
tery. They aie also found in tho intestinal
ulcers and the suiroundmg zone of diseased
tissue
The numerous experiments of Kartuhs, of
Kruse and Pabquale, and others, prove beyond
doubt that when dysenteric stools, or pus from
a liver abscess containing amcebte, are injected
into the rectum of the cat, the amoebae multiply
rapidly and induce a hremorrhagic and uleern-
tive inflammation of the bowel Kiuse and
Fasqualc succeeded in piodncmg dysenteric
symptoms by the pus of a liver abscess con
tailing arncebrc, but which was sterile as
regards bacteria These experiments, apparently
so conclusive, have lost much of their value
since it has been sho\\n by Casagiandi and
liarbagallo that similar b)iuptoms and lesions
follow the injection of hepatic pus containing
neithi'i amo liio noi baetena Jn these cases
the intestinal lisinns must result either from
the initant mituie of the injected ma tonal, or
from tin1 piesencc oi bacterial toxins in the
sterile pus Indeed, Zancarol has icpcatedly
pioduccd, not a dvscnteiy only, but a dysentery
complicated with hvei abscess, containing strep-
tococci, by the injection of hepatic pus destitute
of arncL'bce and steiilo to cultuie In these
cases it is evident that the pus was eithei not
leally sterile, 01 that the nutation set up m
the bowel by the injection had icndcred viru-
lent the haimlcss stieptoccxu present m the
canal, and that these had given rise to the
dysentery and the liver abscess
The expei inients hitheito made in ordei to
determine the pait plated by ,mwb<c in the
dysenteiie piocess aie. tiltogethei mconclusn o.
It will only be when puie cultuies of ainojbu)
have l>een obtained fiom health} and dysenteric
stools, and the expei unents icpeated with these,
that we may hope ioi unequivocal lesults Most
of the expei unents have been made on the cat^
an animal in which non-spec ilic niitants leadily
set up catanhal and ul'ciative inflammation of
tho laigc intohtiiiu It has been too icadily
assumed in these leseaiches that the inflamma-
tion set up in the various expei nnents has been
dysenteiic It is still an open question whether
the A tlywutuur difteis spceihcally, or at .ill,
fiom the J. to/*, and wluthei eithei can give
use to djsenteiy in the healthy bowel It must
also be home in mind that in amcrbic dj senteiy
wo always meet with the battena ot oidmaiy
dysenteiv, especiall} stieptoeocci .ind vaneties
ot the bacillus coh (omniums It is, m fact,
like othci foims of (Ivsenteiy, a mixed infection.
It is possible, although this has not been pioved,
that the amabai leally destioy the bacteiia of
ordinal} dysenteiy, and thus conveit \\hatmight
have been an acute into a chionic piocess But
this would not in eveiy case be a gam, foi we
can readily believe th.it the invasion of intestinal
ulceis by amoeba1 will have Tho effect of con-
verting a disease that would otherwise have
yielded to ticatment into a chionic and intract-
able malady Our recognition of amoebic dysen-
tery as a distinct form rests on grounds which
440
DYSENTERY
are unaffected by the experiments referred to.
Clinical observations associate a peculiar type of
dysentery with amoobeo in the stools. Their
presence in the swollen submucous tissue, in the
ulcers themselves, in the spreading zone, and m
the lymph spaces, proves that they are active
agents in the dysenteric process
ETIOLOGY. — General Condition* — Geographi-
cal Distribution. — Non-amoobic dysentery is a
ubiquitous disease HI tho sense that under
•certain conditions, such as war or famine, it may
appear in any climate As a result of famine,
very severe epidemics have at different times
broken out in Ireland Up to the seventeenth
•century dysentery \vas endemic thioughout the
whole of Northern and Western Europe, and it
occupied by no means an ummpoitant place m
the pathology of the Biitish Islands It is still
to some extent endemic in Sweden, especially in
the neighbourhood of the central lakes, and it
has also appeared icpcatcdly during this ccntuiy
in an epidemic form not only in the lake region
but also in elevated and dry districts Both in
tho northern and southern hemispheres dysen-
tery increases in frenuency an \ve approach the
equator, but not by any moans in a uniform
way. It is notably a disease of tropical and
sub-tropical count ties, in many of \vlnch it takes
the first place as a cause of death Its inci-
dence on different legions varies greatly It is
comparatively mild and tare in Singapore, in the
Malayan Peninsula generally, and in British
Guiana, all within a few degieos of the equator,
while countries at comparatively high latitudes,
buch as tho Noith-West Provinces of India,
Arabia, the Meditenanean shores of Africa,
Senegal, and the coasts of Chili HO fai south as
the 33rd degree, suffer sevcicly The geographi-
cal distribution of amoebic dysentery is still im-
perfectly known As a sporadic disease it
occurs in the central and northern regions of
Europe, and in the noi them states of tho Union
It is more common in the south of Euiope and
the southern states of tho Union It is known
to be exceedingly pie\alont in Kgypt, and is
probably far fiom iare in the tropics generally,
although there is no evidence that it w the
prevailing form of dysenteiy in warm climates
The name, of "tiopical" dysentery applied to
this form is misleading
Altitude —The coast lands and inland valleys
of tropical countries are, as a rule, more subject
to dysentery than the higher lands of the
interior. In India the ratio of admissions fioin
dysentery at stations less than 100 feet above
sea-level is 419, under BOO feet, 32 5 , from
3500 to 8000 feet, 18 7 , and above 8000 feet,
3 8 per 1000 But no altitude affords security
from the disease unless it is sufficient to reduce
the temperature to that of temperate latitudes.
Moderate elevations are sometimes even more
dangerous than the sea-level Bc'renger-Fe'raud
relates that in 1840 the troops m Martinique
were removed to a camp situated at a height of
1200 metres in order to escape from yellow
fever, but it was found that dysentery at that
elevation was as fatal as tho yellow fever of the
plains, [and the camp had to be abandoned
The physical character of the soil, the water, and
circumstances of a climatic kind — winds and
atmospheric humidity — are factors which modify
the influence of altitude
tieason — In tempciate climates dysentery is
notably a disease of summer and autumn. Of
446 epidemics tabulated by Hirsch, 415 broke
out from June to September Fiom August to
October is tho season of dysentery in all temper-
ate climates in the not them hemisphere In
tropical cind semi-tropical countries tho incid-
ence of tho disease in summei and autumn is by
no means so constant as is generally repre-
sented In Ilombay the maximum of admis-
sions into the Euiopean Hospital falls on the
coldest months The percentage of deaths in
tho native arruy of Bengal in the three coldest
months — November to Januaiy — is 39 4, in the
three warmest months — May to July — 16 6 It
is the same in Mann tins, the dy&entciy season
there is from May to August, months of falling
temperature, and diminishing lamiall and humid-
ity August, the ( oldest month of tho year, is
that charged with tho maximum dysentery moi-
trflity As an epidemic disease attendant on
war or famine, dysentery has often raged with
gieat seventy in \\uiter\\hen the tompcratuie
has been extremely low, as was the case in the
('umea m 1854-55
Amoobio dysenteiy is said to be contracted in
most instances in tho warm season
Temperatvte— Fiom \vhat has already been
said of the latitudinal, .iltitudmal, and seasonal
lelatious of dysenteiy it may be mfeired that a
high tompoiature fa\oius its pie valence This
view is suppoitod by tho fact that intemperate
climates the yeais in uhuh dysenteiy is most
prevalent aie, as a rule, exceptionally warm
years The same has also been obseivcd to hold
good in Algiers, Senegal, tho West Indies, and
Biazil. All experience points to sudden fluctua-
tions of tempciatuie in \\arrn climates as a
powerful exciting cause of dysentery. Chilly
nights succeeding \\arm days, exposure to cold
and wet after the l>ody has been overheated,
determine dysentery in countnes where the dis-
ease is endemic It may be remarked that when
tho tempeiature throughout the year is equable,
tho cases of dysentery are pietty evenly distri-
buted over the uhole ycai, but in countries
where tho amplitude ot the annual range is
great, the bulk of the cases tend to be concen-
tiated on a few months In temperate climates
these months are summer and autumn , in
tiopical countries, winter, especially if the nyct-
hemeral variations during that season are also
high.
Soil — The geological formation of the soil
DYSENTEEY
441
appears to have no influence on dysentery pre-
valence. The same cannot bo said of the physi-
cal characters of the soil We have already
noticed its incidence as an endemic disease in
the lake districts of Sweden. The marshy pro-
vinces of Holland recently furnished a dysentery
death-rate double that of the country generally.
According to Kelsch and Kiener, dysentery in
France shows a predilection foi marshy and
moist soils "It is thus," they say, "that the
reports of the Academy continually notice its
occurrence in various departments of Brittany,
in the fluvial districts of the lowoi Loire and its
affluents, in the basin of the Somme, on the
plateaux of the Doubs and the Vosgcs The
southem part of Fmisterc, 1 Ille-et-Vilame, some
districts of the Cotes du Nord, and above all
Morbihan, have atquned in this respect a sad
notoriety " To the same order of fac*s belong
the numeious instances of outbreaks of dysentery
caused by the drying up of lakes and ponds, and
of deposits resulting from inundations, and
cleaning out of canals and reservoirs, and the
exposure of the mud to the action of the sun
The same conditions doubtless favour outbreaks
of dysenteiy in the tiopics What arc the
infective agents giving rise to tho disease in
these instances, and m what way does infection
take place ? These questions do not, as yet,
admit of answci
Relation to Mat ami — D \scuteiy and malaria
aro perfectly distinct diseases, the toimer may
be veiy severe m legions where malaria is
unknown, yet m the tropics they aio often
endemic in the same localities
Ftfcal Pollution oj tiod and Watet — These arc
undoubtedly among the most important factois
in the etiology of dysentery Every epidemy
of dysonteiy is a proof of the mfectiousness of
dyscnteiic e\«icuations, and the disease in most
of these cases seems to be spread dnectly or
indii cctly by soil and w ater pollution Creighton
i elates an mutant e illustrating the way in which
epidemic dysenten becomes diffused The bug
Xandwith \\ith lush emigrants suftcimg fiom
famine dysentery put in at Penzanco on the 7th
of June 1818 Thice of the women passeugeis
died on shoie of the disease On the 16th of
July the disease appealed foi the first time
among the natives of the town No fewei than
500 cases and 82 deaths occurred m the town
New foci were also set up in tho country dis-
tricts by domestics, who, having contracted the
disease m Penzance, had returned to then homes
m the country foi treatment But dysentery
often arises in connection with fiscal pollution
of soil and water when there is no evidence of
specific contamination It is enough for an
army to encamp long enough on a spot for the
soil to become polluted in order to ensure an
outbreak of dysentery The epidemy of dysen-
tery m the Cumberland and Westmoreland
Asylum recorded by Clouston was ascribed to
the emanations from sewage applied to fields
situated at a distance of 300 yards from the
ward where the disease broke out. Dysentery
prevailed in tho Wakeneld Asylum in 1827-28.
The whole sewage of the Asylum, we are told,
was collected in cesspools within a few feet of
bhc wards In these cases the air appears to
bave been the \elncle of infection
Fatally polluted water \\ us the cause of the
numerous fatal outbreaks of diarrhoea and
dysenteiy m the Millbank Penitentiary during
the first half of this century The water-supply
was derived fiom the Thames as it ebbed and
flowed beneath it* walls No more outbreaks
occur icd after a pure supply was provided In
the same way dysentery frequently 'Xjcurred
among tho troops at Cork when their water-
supply was demed fiom tho sewage-polluted
watci of the Lee, and disappeared when another
supply was obtained Examples of this kind,
which might be multiplied to any extent, place
it beyond doubt that fnocally polluted water is
capable of giving rise to dyscnterv There is a
good deal of evidence to show that water con-
taining decomposing oigamc matter, purgative
salts, and othei irntating constituents, favour
the outbreak of dysenteiy More conclusive
cvidenee of the part placed by impure water in
tho causation of djsenteiy could not be wished
than that supplied by Coppmger relating to the
Royal Navy Dysentery, he says, has dimin-
ished m frequency as sanitation in lespcct to
food and \\atei has improved " The proportion
of cases occuiimg in the ycais 1860, 1870, and
1880 respectively, were 127, 3 .">, and 1 2 per
1000 of all the men employed , and \vhcn we
remembei that the use of distilled water on
board ship was coming into general use about
the year 1870, the above figuies arc strongly
suggcstnc of an intimate causative relation
between polluted \\atei and dysenteiy " Many
a death fiom dyscnteiy in tropical countries
would be pi even ted if ti a veil era and others
would adopt the precaution of using only boiled
water
Tainted food, indigestible substances, unripe
and ovei-ripe fruit, excesses of all kinds, especi-
ally in alcohol, predispose to dysentery
Dysenteiy of War and Famine — Severe and
long-continued famine is unifoimly followed by
d\sentory, whether in warm 01 cold climates,
but m some regions more severely than in
others. Dysentery became epidemic m the
kingdom of Naples during the famine of 1763.
Dysentery and diarrhoea were the most fatal
diseases engendered by the Irish famine of
1 847-49. Fi om Ireland the infection \v as earned
by emigrants to the United States, where it
raged from 1847 to 1856 TV the recent famine
in Russia dysenteiy was widely prevalent. Dys-
entery along with diarrhoea never fails to claim
the largest tribute of mortality m India in
famine years In 1897, a year of cxtraoidinary
442
DYSENTERY
misery m the Central Provinces, the death-rate
from dysentery and diarrhoea was more than
four times that in ordinary years. The same
connection between famine and dysentery in
warm climates has been noticed in Seueganibia,
Algiers, and Tunis (Husch) Dysentery of a
spreading kind is a no less constant attendant
on war, affecting alike the tioops in the field
and those subjected to siege In the latter case
the troops suffer in common with the civilian
population. In war dysentery three sots of
factors come into operation, (a) conditions
which predispose the system to the disease,
among which aie bodily exhaustion, exposure to
heat and cold, lying on damp ground, over-
crowding in the case of besieged garrisons, and
often scarcity and biul quality of food , (b) con-
ditions which moie directly dctcimuic infection,
such as the pollution oi soil and Mater by isecal
matters,, (r) facilities for the spread of the
infection when the disease has once made its
appearance among a densely masked body of
men.
Personal Conditions — Race — It is ficujicntl^
stated that Kuionjans in warm climates are
more liable to dysentery than the natives
This is not the case in India The admission-
rate per 1000 of the European ainiy of India,
(1897) was 15 7, that of the native aimy 66 4
All a//6S miffet fiom dysentery If we include
under dysenteiy the luemonhagic catairhal
complaints of infancy and childhood, dysenteiy
makes most victims m those undei five ycais of
age In 1878, the dysentery dcath-iate of the
army ot India was 1 73 per 1000, that of
European childiou 381 pei 1000 The test*
suffer in neaily the same pioportion The pooi
suffer moie than the nch Dysentery is moie
pievalcnt in small towns and villages than in
largo cities Theio is no acclimatisation foi
dysentery Dunng hit* first yeai m a tiopual
country the Kmopean is more liable to the dis-
ease than in the two or three follow ing yeais
but after the fouith or fifth year the liability
appeals, upon tho whole, to increase, atcoiding
to the length ol icbidenco in the tiopics
PAnroLOMCAL AvAioan — Xon-anurlic Form
— From tho stand-point of pathological anatomy
non-ainojbic dysenteiy piesents thiee varieties
(«) That in \\hich there is no cronpous 01 diph-
theritic deposits, the lesion* being inflamnuvtoiy,
uleeratue, and gangienous This, for the sake
of distinction, we shall speak ol as infiaiiirnatoiy
dysonteiy , (A) In anothei \anety the surface ot
the miHosa piesentHucionpoiis deposit, the sub-
mucosa being little 01 not at .ill affected This
is cionpous dysenteiy (r) In a thud class of
cases the mucous and sub-mucous coats are the
seat of exudation— *»liphtheiitic dysentery Tho
croupous and diphthentic vaiiotios appear to
be grades of tho same process Tho cioupous
form necessarily terminates m nlccration, which
is principally supeifieial , tho diphtheritic ends
m ulceration and sloughing of the mucosa and
sub-mucosa, and often enough of the muscular
coat. Tho lesions of two, or all, of these varieties
may bo met with m a single case.
As regards site, dysentery is generally most
marked at one or other extremity of the large
intestine, — the ceecum and ascending colon, or
the descending colon, sigmoid flexure, and rec-
tum. I have often seen, however, tho whole of
the large intestine so involved that it was
difficult to say what particular part was most
affected
A cataiihal inflammation is the initial stage
of all the varieties mentioned The mucous
membrane at the seat of the disease is more 01
less thickened, of a daik red coloin, studded
with ecchymotic points, and covered w ith blood-
stained mucus The congestion is either tolei-
ably uniform ovei a large sin faee, or is disposed
m streaks or parches affecting chiefly the mucous
folds This stage is often obweived in certain
parts oi the bowel when the disease has already
gone on to uleciation and sloughing in othei
places In a ease obseived by Houston, m
which death occuricd aftci t\vo da^s' illness,
the mucous meinbiane of the caecum was found
to be reddened and thickened in small pntcncb,
which ran into one anothei like the vt upturn of
the skin in measles The tiai^eise colon was
mottled and thickened, the descending colon and
rectum was less affected In the lectum the
mottling \\as mixed with led points the si/e of
a pin's head Them was no ulceiation, although
tho stools contained blood, and no meinbianous
deposit had yet appealed, although the epidemy
in which the case occiuied was of the cioupous
kind In the cataiihal stage the capillaries and
small veins are engorged , the follu les are often
suiiounded by a sumo of congestion The epi-
thelium is paitially detarhed, and the sohtaiy
glands aie often mini 01 less enlaiged
When the disease in the mjlamniatoty ^allety
has ad^anced beyond the catatih stage small
neciotic spots situated in the mucosa arc often
obseived, along with ultei.ition, and it is not
improbable that the ulceis m most cases start
fiom these necrosed foci The ulieis increase
in si/e and depth, and are geneiully tiansveiso
to the tv\is of the gut In scvcic cases, bide by
side with ulceis, aie sloughs of an ashy 01 dark
eoloui, 01 the allected poitions may be found
couveited into a daik putiesoent mass Excep-
tionally, the whole ot tho large intestine is
gangicnons, and on opening the abdomen tho
bowel may bo seen, .is C'hevers expressed it,
coiled up like a dead snake, a flaccid gangtenous
mass A case u iccoided and hgiitcd by Cayley
in which the whole of the mucous membiano
from the ciecum to the anus piesented tho
appearance of a suppuiatmg soi e Whether mild
orso^ere, no cioupous or diphtheritic deposit
is observed m the inflammatory foim. The
calibre of the bowel is not narrowed, and w hat*
DYSENTKRY
443
ever may be the degree of thickening resulting
from oedema or (suppuration, the bowel is never
rigid.
The croupous variety, as we have already seen,
begins with congestion, ecchyniosis, and thicken-
ing, followed by a croupous deposit This presents
itself eithei as a soft, jelly-like layer, which may
be rubbed off from the mucoba, not, howe\cr,
detaching tho epithelium, or it occuis as» a firm
and adherent deposit of a grey, rusty, or black
colour. In bonie cases it appears in isolated
speeks limited to the folds of tho mucosa, in
otheis it foims \\aity masses, disci etc or con-
fluent, involving linger or smaller but faces of the
mucoiib mcmbiane That this is not a uuiplc
necrobis of the suiface of the mucosa, buch as is
hecn in the inflammiitoiy variety, is proved by
the epithelium being found in situ undci the
adhering layer This deposit consists of a
granulai, sometimes indistinctly fibiilla'ed, sub-
stance enclosing led corpuscles and bacteria
The undei tying mucos'i is thickened fioni ton-
gebtion, adem.i, and increase of tymphoid ele-
ments The sin face deposit dips down into
the tubulai glands, which become distended by
hypcrplasi.1 of then lining epithelium,, com j
pressed and distorted by piessine , sactulaUd
by obstiuction fioni \\ithm 01 by piessine fioni
without The solitaiy glands aie often enlaiged
€iud prominent, and at a latei peiiod become
ncciosed, leaving small, lound, punched -out
ulceis As tlic disease progi esses, the deposit is
detached, leaving- an ulceiated siuface The
ulcei is at hist limited to the inucosa, but it
may afteiwaids gain in depth and successively
nrvolve the sub-iuucous and muscular coats
In the i^iphthi) itic vanity tho l)owel becomes
thickened and Jigid, and its cahbie nano\ved
Intenially, the allectcd poitions are v ai legated
in colon i and uneven on the suiface The AN. ill
of the bowel cuts like biawn, the section pie-
scntmg a sticaky yellowish and red .ippeaiance
Micioscopicallj the most notable appeaianccs
are engoigeiuent of the blood-vessels, dilatation
of the lymphatics, thickening of the walls of the
smallei A ems, increase of small cells, and the
presence ot an amoTphous gianulai substance in
tho meshes of the connective, tissue, tho cells of
which undeigo degenerative change
The necessaij tet initiation of the diphthentic
fonn is .sloughing and gungiene The sloughing
arises in some cases fiom the compression of the
vessels .ind tissues by the exudation and the
multiplication oi Ijmphoid cells, but, in othei
instances, auest of the en dilation of blood and
lymph f lorn tho action of the vnus appeals to
give rise to neciosis, sloughing, and gangienc
Amvtliic Dywntny—ln ameubic dyscnteiy, to
uso the woids of Lafleur, "thickening of the
bowel is a constant and veiy chaiactenstic
feature It may involve all the tunics, but is
especially marked in the sub-mucosa, and is
sometimes limited to it It consists in a gcneial
oedema, and m localised areas of thickening,
which appear on the surface of the mucous
membrane, especially its folds, as sharply cir-
cumscribed hemispherical 01 ovoid piojectious,
over which the membrane is slightly /eddened
or discoloured. "When incised they t.te found to
contain a pale 01 greyish-yellow, \iscid material
consisting of detntus of tissues, led coipusclcs,
and amojbdL* " When the mucous membrane
gives waj, ulcers are foimed, which tend to
bunow beneath the mucouo coat, and often
communicate \\ith neighbouring ulcers Tho
ulc<r is pruiuiiily seated m the. suh-mucosa, and
spiea.dk bj fuithei initiation and softening of
the suiiunnding thu kencd sub-mucous tissue.
Its edges ue lagutd, the base sloughy, clean, or
giamilatmg denuding to the stage invvhuh it
is found
The micmMiipH appeaiames .11 amoebic
djsrnteiv difiu little irom those met with in
other foiins We have the same engorgement
of blood and Ijmph vessels, the same ci'dcmatous
thickening, the same me i ease of small cells
The connective tissue cells nndeigo degeneration,
and the intercellular substance becomes con-
veited into an amoiphous, granulai mass
The glaiidulat structines aie only sciondaiily
aftecte d
The lesions oi (hionic d}senteiy aie inultifoiin
As lesults of the pumaiy acute attack, we meet
with hbious hands or jttai/Hf\ ionned dm ing the
piocess oi lepaii These SOUK times give use to
eonstiictions of the gut Side 1$ side with
these may be found poitions of the bowel which
have undeigone atinph}, involving moie oi less
all the coat^ 01 (unfilled to the glandulai stiue-
tuieh As a lesult of the chiomc mfl.immatoiy
process, we meet with moie oi less diiluse thick-
ening and induiation In some cases the affected
portions of the bowel aie semi (aitilagmons to
the feel Chiomc ulcers aie also ficqmntly met
with, especially above eonstiictions or contrac-
tions When death has follow ed an acute
exaceibation the lesions chaiaetciistie of tho
acute1 foiin v\ill also be piesent
ASSCH i\m> I'Ainoiridi — The mesenteiic
glands in acute ctyscntciy aie engaged «ind
hypeiajnne , in the chiomc disease, enlarged,
piumented, mdii'atc'd, and som< tunes the seat
of chees} deposits When ulceialion has ended
in poifoiation diftnse peiitomtis will be found
Much moie fiecnientl> peifoiation is pievented
liy paitial peiitomtis, with efhision of l}inph and
the foiniation of adhesions to the ncighbouimg
viseeia Tin1 colon may thus be adheieut to tho
coils of the small intestine's, to the stomach, to
the mulct suiface of the liver, 01 to the spleen;
these adhesions often senously affect the func-
ti( >ns of the 1 >ow el In a con yd ei al >le pi oportion
of cases of tropical dyscntei}, especially of the
amcebic kind, the hvei is the scat of solitary or
multiple abscesses, oi of pyjcmic deposits It
may also be found congested and hypertrophicd
444
DYSENTERY
without abscess The spleen is usually normal,
never enlarged unless as a result of a malarial
complication; in exceptional cases it contains
suppurating foci. The kidneys in acute cases
are generally healthy, but when septicajmia has
developed they may exhibit the lemons of acute
nephritis. In chiomc cases they not infrequently
present the characters of one or othci of the
forms of chronic Hnght's disease
JRqjatr — The process of lepair in all forms of
intestinal ulceiation is the same, and differs in
no respect from what is obseived in ulcerb else-
where. Granulation tissue springs uj> in the
base and sides of the ulcer Its codcmatous or
indurated edges become levelled do\vn by absorp-
tion, ovoi hanging portions of the mucous coat
become attached to thu subjacent tisbue. When
the loss of bubbtance has been comparatn ely
limited no cicatux icmains, and little beyond
pigmentation marks the site of the ulcer Ex-
tensive ulcers heal by the formation of ucatiiual
tissue, which lestoios the continuity of the bowel,
but too often leads to constrictions
SYMPTOMS — Non-A tntrbic Dywntet y — When
the disease is epidemic, dysenteiy frequently sets
m suddenly, the patient having up to the time
of attack been in peifcct health In the endemic
dysentery of uarm climates cases aie now and
then met with in which the d} sentenc s) mptoms,
as Annesley remarks, are prebent " from the first
hour at \\hieh the patient complains." It is in
these cases that the disease is apt to be ushered
in by a chill 01 ngor Mote fiequently the
advent of the disease is less abiupt " Tho
patient has been troubled for a Meek 01 more
with constipation, or alt ei nations of constipation
and bilious, mucous, 01 seioub diaiihoea In
other cases by mptoms of indigestion precede
the attack, which then begins as a simple
dianhcea In whatsoevei way the disease
begins the first motions are usually loose and
feculent, they then become un\ed with blood-
stauied mucus After a time the fteees dis-
appear from the stools, which no\\ consist of
little else than blood and mucus The motions
are preceded by bevere colicky or gi ipmg pains
and are passed with straining Straining is
most imuked \\heu the disease is seated in the
sigmoid flexure and lectum The number of
motions ^arles according to the seventy of the
disease In mild cases the stools do not exceed
ten or fifteen in the twenty -foui houib ; in severe
cases there may be as many in an hour, and the
desire to go to stool is constant Long, painful
straining results in the p.issmg of a small quan-
tity of a gelatinous, semi-transparent, sometimes
bile-coloured mucus, tinged with blood, which
affords little or no relief Tho patient is with
difficulty induced &o quit the commode In
some cases blood is more abundant, and small
clots may be passed
The constitutional symptoms during this stage
are comparatively slight, even when the motions
are frequent and the pain distressing There
is little or no rise m the temperature. The
pulse is slightly increased m frequency, the
tongue is coated, the appetite impaired, occa-
sionally there is nausea, but seldom vomiting
unless the liver is involved. The patient is
estless and irritable.
Such are the loading symptoms of the catarihal
stage If the disease is arrested at this point
the bowel suffers little damage, and recovery is
usually rapid and complete if ordinary care is
taken during convalescence
The first sign of improvement is the reappear-
ance of fccces in the stools This is followed by
a decrease m the number of motions, the dis-
appeaiance of the abuoimal discharges, and the
iclief of the griping and straining
Should the disease continue to make pi ogress
the stools undeigo a change They lose their
mucous, slimy charactei and become watery,
of a dark-red colour, not unlike the washings of
meat. Then odoui is distmc-tn e, and sui generic
different alike from the mawkish smell of the
first and the distinctly gangienous odoui of the
third stage When allowed to lest a sediment
subsides, consisting of epithelium, blood cor-
puscles, pus cells, dobiiH of tissue, and small
shreddy sloughs The fluid poition is found to
be rich in albumin It has been estimated that
m a dysentery of model a to se \enty some fifty
01 si\ty giammes of albumen is discharged daily
In this stage prolapsus of the bowel is often
tioublcsome, and when the disease is seated in
the rectum the bladder often becomes affected,
and clysuna, sti augury, and retraction of the
testicles supervene, giving rise to moie distress
than that caused by the symptoms directly re-
feiable to the bowel Tho constitutional symp-
toms during this stage are more maikcd There
may be moie or loss fever of a remittent or
intermittent type, with evening cxaceibations
The evening use m the temperature seldom,
however, exceeds two or thieo degiees Fahren-
heit, if the case is uncomplicated The pulse is
fast, weak, and soft , the tongue tends to become
dry, there is generally cntiie loss of appetite,
there is thirst, nausea, perhaps occasional vomit-
ing, the mine is scanty and may contain traces of
albumen, and there is rapidly mci easing emacia-
tion and debility Tho intermittent colicky
pains of the first stage continue, and there is
sometimes added a peisistont feeling of uneasi-
ness or distinct pain in the tiact of the large
intestine, increased on pressure.
If the disease now takes a favourable turn
the stools become feculent and all the symptoms
moderate, but the convalescence is prolonged,
and is apt to be interrupted by the slightest
imprudence in diet or regimen
The transition to the third stage is marked
by the stools assuming a distinctly gangrenous
odour, becoming less watery, of a dark-brown
coffee colour, sometimes with a greenish or
DYSENTERY
445
yellowish scum, and containing shied s and
sloughs, and sometimes blood -clots The
sloughs are of various colour, size, and thick-
ness. Some aie thin and shreddy, of an ashy,
olive, or daik colour indicating gangrene of
the mucosa, others aie thick and pus-infil-
trated, derived from the mucous and sub-mucoiib
coats In compaiatively rare instances tubular
sloughs are discharged I ha\e seen sloughs
of this kind seveial inches in length These
may project for a time from the semi-paralysed
anus, causing much pain Dutroulcau i elates
a case in which a patient recovered after passing
nearly 14 inches of tho mucous and sul>-mucous
coats Another case of recovery is recorded
by Fayrei in which a daik-grey tubul.u slough,
about a foot in length, was first discharged, and
then another three inches in length It is not,
however, to be concluded iiom such instances
that recovery is anything but a \ery iare event
when tubular sloughs consisting of the coats
of the bo\vel, and not of croupous deposits, are
discharged The few cases of this kind that 1
have seen pioved fatal
When the gangienc is progicssmg to a fatal
termination the pains subside The anus be-
comes relaxed and patent, the motions pass
mvoluntaiily, the tempeiatme oiteii falls below
the normal, the features become shiunken, hic-
cup supeivcncs, and the patient dies in a state
of collapse Typhoid b}inptoms, on the other
hand, may de\ clop, and the temporal me then con-
tinues above the noimal Occasionally perfoia-
tioii occurs, and the patient succumbs to acute
peritonitis When the strength is maintained,
and algid and typhoid symptoms aie absent,
hope of recovery is not to be abandoned
I described in 1893 a foim of dysenteiy in
which tho coccum and ascending colon aie chiefly
affected, which often follows or is complicated
with malaria This was the pievailmg type
of the disease in tho Ash.intee campaign of
1874 In this foim the motions at first aie
loose, fiothy, yellowish or gieenish, mixed with
mucus and blood, and passed with little strain-
ing. As the disease advances they become
chocolate-coloured and deposit a grumous sedi-
ment of pus, blood, shreds, and sloughs What
appears to be the same type of dysentery has
since been described by Babes, who supposed
it to be peculiar to Roumania Marchiafava has
met with similar cases in Italy, and has found
it to be a mixed infection of amoeba), bacillus
coh, streptococci, staphylococci, and other bac-
teria. This disease runs an acute course and
seems to be only met with in malarious regions
We have tried to depict the more common
features of non-amoobic dysentery, but every
individual case presents certain peculiarities,
and considerable differences m respect to par-
ticular symptoms are sometimes observed. In
some cases, for example, the stools remain fecu-
lent throughout tho catarrhal stage, or there
is an occasional motion of green or yellow fecu-
lent matter The frequency of the stools is not
always m proportion to the seventy of tho disease.
I have notes oi fatal cases in which the stools
have not exceeded twelve m the twenty-four
hours Sloughing occasionally takes place when
the mucous stools would indicate that the disease
is in the first stage The second and third
stages arc occasionally not defined. Vomiting
is sometimes an urgent symptom when, after
death, no disease of the In or IH found It may
finally be noted, as a point of some prognostic
importance, that hiccup may persist for days
m comparatively mild cases The gravity of
this symptom when combined with prostration
and a typhoid rendition is well known.
Amafai Dy^ntny is gradual, as a rule, in its
onset, intermittent in its progiess, and pro-
tracted in its course It gene -ally inns cm-
for tn.ni} months, and sometimes for one or
two jeais It begins foi the most part with
a painless diarihcra, with mtenals m which the
motions aie formed or the bowels constipated.
The stools dm ing the cxaccibalions are loose
and yellowish, and contain mucus, and occa-
sionally a httlo blood This state ot things
may continue pietty much throughout tho
tedious comse of the illness, the patient losing
in flesh, and becoming weak and aiunmc The
real natuie of the malady may only be dis-
covered when symptoms of h\ei abscess supci-
vene In moie severe cases the periods of
quiescence aie short, the exaccibations frequent,
proti acted, and sc^eie Dm ing the exaceiba-
tions the stools aie loose 01 watery, yellow,
greenish, 01 grey in coloui, and contain mucus,
with streaks 01 clots of blood, and small gela-
tinous nccrotic masses demed fiom the in-
testinal ulcers The patient suffeis fiom colicky
pains, but theic is little tenesmus
OraAe symptoms may appeal suddenly in a
case that had pre\iously been running a mild
course, or the successne e\aceibations may in-
crease in «e\enty until the disease assumes a
dangerous tjpe In this grave foim the patient
sufleis fiom sc\eie colicky pains, and in some
cases from a minor degree of tenesmus The
motions number twenty or thirty daily At
first they are scanty and contust chiefly of blood
and mucus , at a later period they become more
copious and watery, are extremely offensive, and
contain debris oi tissue and sloughs When
these cases run on to a fatal termination the
general symptoms are those of tho gangrenous
dysentery already described
This severe foim may bo primary, in which
case the disease begins abruptly and runs on
in a few weeks to gangrene It will probably
be found that m these aciftc cases tho bacteria
of ordinary dysentery play the principal idle
Chronic Dysentery — Chronic dysentery cither
begins insidiously, developing out of a simple
diarrhoea or a subacute form of dysentery, or it
446
DYSENTERY
is a sequel to the acute disease Many of the
oases of tropical dysentery which begin insidi-
ously as an mteinnttent diarrhoea arc probably
amoebic, but we meet with cases, chronic from the
beginning, which are cleaily non-amoebic These
cases often run a much more protracted course
than amoobic dysentery We meet with instances
of this vanety which persist with intervals of
quiescence for seven, ten, or fifteen years
Chronic dysenteiy is, howevei, generally a
sequel of the acute disease The acute symp-
toms subside, but a tendency to looseness per-
sists, \uth occasional tiaecs of blood and unions
in the stools, and reouning attacks of colicky
pains 01 of abdominal discomfoit These symp-
toms disappear for a time, and the patient re-
sumes his oidmaiy habits, when a subacutc
e\acei nation shows that the pnmaiy attack had
left behind it latent mischief \\hich a chill 01
some slight indiscretion in diet sufficed to stir
into activity Now follow penods of quiescence,
during which ioi a few days or weeks the bowels
may be noimal 01 constipated, the picvailing
condition, however, being a tendency to loose-
ness These altcmate with periods of e \acei ba-
tion during which the stools are dysuitenc and
passed \vith griping and shaming The appe-
tite after a time is lost or becomes capricious,
the digestion is impaiicd , often thcie is nausea,
occasionally vomiting, and the patient emaciates
and becomes an.rimc
When the bowel has become nariowed by
cicatuces, or its action impeded by adhesions
lesultmg from the pi unary attack, 01 by thicken-
ing set up by the chronic inflammation, the
symptoms of intestinal stenosis develop The
evacuations aie passed with difficulty, the
abdomen becomes tumid and tender, there is
a distressing feeling of distension, the bieath
acqimes a feculent odour, the complexion be-
comes earthy, the tongue glazed, the skin diy,
and the patient sinks from exhaustion or is
earned off by some mtei current malady.
SPECIAL FORMS AND COMPLICATIONS — Afalatia
— Wo must distinguish between dysentery com-
plicated \vith malaria, and dysentery cawed by
malaria When the patient is not immediately
suffering from nialanal paroxysms, the fact of
his haung recently done so sometimes shows
itself either in an evening rise of temperature
or in a leturn of aguish attacks. Tn many
instances the previous malaria has no effect
whatever on the course of the dysenteiy. An
evening rise of from one to three degrees is often
ascribed to malaria when it is really caused by
septic absorption When dysentery coexists
with actual paroxysms of malarial fever, the
two diseases may run their course without the
one poiccptibly influencing the other. In other
instances the dysenteric symptoms become aggra-
vated dining the paroxysm, but the contrary
result is also occasionally observed, the dysen-
teric symptoms subsiding during the fit.
There is a form of pernicious malarial attack
which is characterised by intermittent dysen-
teric attacks The symptoms subside or dis-
appear during the intermission to recur at
quotidian or tertian intervals This is an ex-
ceedingly rare form of pernicious fever Much
more common is an intermittent intestinal
hcomorrhage The blood passed may bo pure
or mixed with faeces In these cases we have
to do with malaria, not with dysentery But
malarial fever may give nse to perhaps more
than one special form of dysentery, which may
bo looked upon as substantive diseases The
fevei -stricken troops in the gieat fevei epidemy
in Mauritius m 1866-67 were attacked with a
dysentery characterised by discharges of a thin,
smoky, dark fluid, with no trace of feculent
matter Sometimes sloughs were passed, some-
times none Theic was a maiked tendency to
collapse On autopsy a total sloughing of the
large intestine was obsened in some cases,
while in others the only morbid appearance was
a prominent state of the glands ipecacuanha
was of no set vice in this form of dysentery, but
laige doses of pcichloiide of iion were fiequently
usciul
ticotlmtus — In pei sous suffeim£» from scurvy
dysenteiy begins as a diarihoea, and throughout
its couise the motions arc generally moie copious
and less frequent than in the oidmaiy forms
of acute dysentery The stools consist of f.cccs,
mucus, and a considerable amount of sanguine-
ous fluid, often with sloughs The tormina and
tenesmus are less severe The ordmaiy symp-
toms of scurvy will, of course, be present It
must be lemembcred that if scotbutus predis-
poses to dysentery, so does chronic' dysentery
predispose to scurvy. The combination of these
two diseases foims one of the most fatal maladies
in besieged cities
Rheumatism of the large joints has been very
common in some epidemies of dysentery m
Europe One joint aiter anothei may be
attacked, or the disease may be confined to one
joint, generally the knee The swelling and
pain are considerable, but it is larely accom-
panied by fevei, and still more rarely does it
terminate in suppuration It is analogous to
the joint affection of Malta fever.
Paraplegia of a reflex character is an oc-
casional sequel both of acute and chronic
dysentery
Epidemic Gangrenous Rectitos, the Caribi or
Buck sickness of British Guiana, is a highly
infectious malady, which has repeatedly occurred
in destructive outbreaks among the Indian
population. It has also been met with m
Trinidad, Brazil, and Peru, in which places
the white population has not been spared.
The same, or a similar disease, combined with
a gangrenous stomatitis, is said by Corney to
be one of the most fatal diseases in Fiji and
some of the other islands of the Pacific The
DYSENTERY
447
leading symptoms are those of gangrene of the
rectum with dilatation of the sphincter am
The disease w generally limited to the rectum,
but it occasionally attacks the transverse colon
primarily , hence a distinction is made between
the "high" and "low" forms In other in-
stances the disease beginning in the rectum
afterwards involves the whole of the large
intestine
DIAGNOSIS — In simple and ulceiative col it if
the stools contain blood and mucus, and in the
ulcerative form, pus and sloughs are piesent,
and hvei abscess may develop The chiet points
of distinction are that in ( olitis we do not have
the serous stools like washing of meat, nor the
same constant desire to go to stool, nor the
severe toimma and tenesmus generally met
with in dysentciy
Rectihb difteis from dysenteiy 11 this, that
although there ate* frequent stools of .1 dysenteric
Kind, with tenesmus, the patient passes healthy
motions daily 01 eveiy other d.iy, according to
his habit
DiUtarzid disease of the sigmoid flexure and
lectum simulates sub<i<ute and diromc dysen-
tery. An examination of the stools, and of the
muoosities detached fiom the 15ilhar/ia infarc-
tions ot the bowel, for the eggs of the parasite,
mil reveal the tine natuic ot the disease
The diagnosis of the amojbic form will
depend on the discovery ot the amceb.e m the
mucus, the gelatinous neuotio masses, and the
f.eoes The stools should be kept at the tem-
peiature of the blood fiom the time they aic
passed until the e\ainm<itioii is finished
The diagnosis of the incidents arising during
dysenteiy «f»eldoin piesent much difficulty In-
vaginattoH, of the bow? occasionally occurs
during tho comse of dysentciy and diairhoja m
children The sudden change m the condition
of tho patient, the supcivcntion of vomiting, at
fiiat of the contents of the stomach, and finally
of feculent matter, the tympamtic state of the
abdomen, pain on ptcssiue at the site of the
mvagination, without gencialiscd tenderness,
indicate the natuie ot the accident The
symptoms of perforation are those of acute
generalised peritonitis, and cannot be overlooked
or mistaken Acute limited peritonitis resulting
from inflammation of the serous coat of the
bowel, consequent on an ulcer penetrating to
or below tho muscular coat, gives rise in many
cases to moie or less generalised abdominal
pain, but the tenderness is limited to the
part m which the disease is seated The
abdomen is not tympamtic, and the constitu-
tional symptoms of perforation or invagmation
are absent
MORTALITY AND PROGNOSIS. — The case
mortality m the army of India, which was
about 11 per cent m tho ten years ending 1857,
fell to 3-3 per cent in tho five years 1871-75
A corresponding decrease has taken place m
the French army In war times, not only does
the number of cases increase, but also their
fatality In the German military practice
during the war of 1870-71 tho case mortality
was 6 per cent
The marked decrease in the case mortality of
dysenteiy during the last half-century is in
part, 110 doubt, the result of impiovcd methods
of treatment, but to a much larger extent it
is the effect of improved hygiene, which has at
once lessened the prevalence and the seventy
of the disease The army returns include
many casc-> of tho mildest foiins of the disease
that aiu dvsentery in little else than the name
A moio just idea ot the giavity of the disease
is to be gathered from the mortality in cases of
sufficient grauty to rcquue admission into
<ml hospitals In the Calcutta Hospital
(1879) the i,itio of deaths to admissions was
22 2 , m MauutuiH (1888) it was 22 7 per cent
The piognosis must always be guarded, as
the mildest <ases me liable to undergo un-
expected aggravations, and this is especially
true of ainuulno dysentery hi epidemic dysen-
tery the t}pc of the outbicak has also to be
taken into account, as some epidemics arc much
more fatal than otheis The passage of the
disease fiom the mucous to the scious stage,
notwithstanding early and efhcient treatment,
lenders the prognosis more grave The im-
mediate dangei is inci eased, and the nsk of
the disease becoming chiomc is gi eater The
prognostic significance of sloughs m the stools
depends not only on their number, size, and
thickness, but also very much upon the way in
which the patient supports the disease When
the stools piesent a gangrenous odour and the
patient is piostiate, the piognosis is grave even
if there aie no sloughs in the stools Typhoid
symptoms, or a tendency to collapse, are
ominous, and all the moie so if hiccup is
conjoined with these svmptoms
In foiming a judgment respecting the probable
issue of a case of chrome dysenteiy we have to
take into tonndeiatiou not only the seventy of
the symptoms, the duration of the disease, its
effect on the patient's health, the presence or
absence of conti actions and adhesions interfering
with the functions of the bowel, but we must
also take into account the ability of the patient
to obtain change of climate, rest, and care, and
his readiness to submit to those icstnctions m
tespcct to diet and modes of life upon which
the success of treatment laigely depends
Puopim AXIS — The methods now being tried
of producing an immunity by the use of pro-
phylactic scrum are as yet outside the sphere
of piactical medicine, and our chief hope will
probably always lie m obviating the pi ©disposing
and exciting causes of the disease. The recog-
nition of tho infectious nature of dysentery lies
at the loot of its prophylaxis. Dysenteric stools
should be disinfected, and either deeply buried
448
DYSENTERY
at a distance iroin dwellings or ciemated. Soil
in the neighbourhood of dwellings and drinking-
water should be guarded from frecul pollution.
In countries where the disease is endemic the
precaution of boiling the water before using it,
unless it is above all suspicion, should never be
neglected The influence of muscular ex-
haustion, of exposure to cold after being heated,
of insufficient nourishment, of excesses in food
and alcohol, in predisposing to dysenteiy must
be borne in mind Other measures of pre-
vention will be deduced from a careful study
of the etiology of the disease
TBKATMENT. — Of piimary importance in the
treatment ot all forms of dysentery arc rest and
diet The patient is to be stnctly confined to
bed throughout an acute attack, whether mild
or seveie Kvcu motion in bed is to be avoided
as far as possible. The bed-pan bhould be used
to obviate the necessity of the patient getting
up to stool
Fresh milk given lukewarm is, perhaps, the
best diet in most cases When fresh milk
cannot be obtained, condensed milk may be
substituted When ordinary milk is not well
digested, peptoiuscd milk, or milk diluted with
lime water, may be found to ans\ver In a
considerable number of cases milk in any foim
disagrees Afansoii remaiks that when the
tongue is coated milk is often not well borne
This is true, but it also occasionally disagrees
with patients when the tongue is clean Tn
those cases good beef tea, chicken soup, or
barley water may bo substituted Whatever
may be the food selected, it should bo given in
small quantities in the intervals between the
doses of ipecacuanha, if this remedy is used
As a nile, alcohol is not only unnecessary but
hurtful, but in some outbreaks the free use of
wine and water has done good
The casual indication, which is to destroy the
pathogenic agents of the disease, can only bo
imperfectly carried out Salol has been recom-
mended by Rasch, Fisch, and Kartulis It
may be given in 15 to 20 gram doses in cachets,
and may be used along with castor oil or other
purgatives Naphthalm has been given by
mouth and enema with some success by
Rossbach and NovikofF It may bo given in
15-gram doses four times daily by the mouth,
or in enema dissolved in olive oil or suspended
in some mucilaginous menstruum.
Benzo-naphthol appears to bo deserving of
further trial. It has little toxic power It
passes through the stomach unchanged, break-
ing up in the intestine into beta-naphthol and
benzoio acid It is specially indicated when
the kidney is diseased Thirty to fifty grains
or more may be ^iven daily in divided doses.
In the present state of our knowledge these
remedies are rather to be looked upon as
auxiliaries to other methods of cure, than as
means of cure to be trusted to alone.
The indications from the disease arc to prevent
the healing process being disturbed by the
passage of cxcrementitious matter over the
inflamed surface, and to secure rest for the
bowel by the use of sedatives, such as Dover's
powder. Of the importance of a non-irritating
diet enough has been Raid Experience proves
that there is danger in attempting to arrest the
peristaltic movements of the bowels by opiates.
Many cases may recover under such treatment,
because many cases will recover without any
treatment other than rest and dieting, or in
spite of inappropnato treatment. I have seen
this method of securing mechanical and physio-
logical rest for the bowel tiled on a large scale
by an eminent physician, and I am bound to
say that the results were disappointing
The symptomatic indications are to relieve
pam and local irritation Small opiate enemata
are occasionally useful when tencsmus and
dysuna aic distressing Poultices, fomenta
tions, and turpentine stupes often afford con-
hideiable iclief Poultices if they are to be of
service should covei the whole alxlornen, and
be icnewcd before they begin to feel cold to the
patient A wann bath given at the commence
meut of the disease is useful if one be taken tc
prevent a chill.
Quito recently serum methods of cuie have
been tued, but their value has not yet been
demonstrated
The most successful treatment of dysentcrj
is purely empirical, and consists in the use ol
ipecacuanha, salines, or mercurials Ipecacuanlu
and salines aie altcrnati\o remedies adapted tc
the same forms of the disease In severe cases
if there is no contia-mdication to its use
ipecacuanha should, I think, be employed
Salines arc to be picfeired m the case of younj
children, delicate peiHons, pregnant women, an<
when ipecacuanha cannot be tolerated Mercmj
is to bo resorted to m those cases only m whicl
the other remedies have failed, and in epidemiei
m which they have been found inefficacious
As it is impossible to distinguish fiom tin
symptoms the class of cases likely to be bcnefitcc
by one or other of these remedies, the ipeca
cuariha or saline treatment should always b
employed in the first instance, and rcceivo i
fair trial
Use of Ipecacuaitha — The method of usmj
ipecacuanha is as follows —The patient shoul<
abstain from food and drink for three hours 1
large sinapism is to be placed over the abdomen
and 30 to 60 grains of ipecacuanha powder ar
to be administered in bolus or cachet. Mor
or less nausea will result, and .'after a tim
vomiting generally ensues. If the drug is re
tamed for three-quarters of an hour or longei
its curative action will not be impaired even i
a considerable portion of the powder is the<
rejected These doses are to be repeated twic
or three times daily, according to the urgenc
DYSENTERY
449
of the case and the tolerance of the remedy, and
are to be persisted in until the symptoms sub-
Hide or until it is evident that the treatment is
ineffectual No od vantage* in the way of pre-
venting nausea is to be expected fioin a reduc-
tion ot the dose, foi laige doses often give rise
to less disturbance than small ones Nor is
vomiting, unless excessively pi oil at ted, to t>e
looked upon as something to be avoided On
the contrary, by cmulmng tin- bile-dmts, by
causing fiee peispnation, and by the general
succussion of the system to which it gives rise,
the emetic action of ipecacuanha is salutary in
dysenteiy. Should the lemedy be i ejected
Khoitly after it has been taken, twenty drops of
laudanum should be given befoie the next dose,
the mustaid plastei being again applied
The hist sign of impiovement is usually the
appearance of fceces in the stools, followed by
an abatement of .ill the symptoms The remedy
should be continued at longer mteivals until
the blood and mucus has disappeaied from the
stools if dial il icra continues, it may betieated
with Dover's powdci 01 bismuth
Dc-emetmised ipecacuanha has been iccom-
mended m the tieatmeut of dysenteij, but its
value .is a substitute ioi the ordinal y po\vdei is
<loubtiul
»S''i/f/tf Tientmtnt —In the saline treatment
the sulphate oi sodium is the salt generally
piefeiied, .is being less nauseous and irritating
than the magnesium sulphate Thiee-quaiteis
of an ounce, more oi less, accoidmg to the age
of the patient and the effect of the diug, is to
be given either in a single dose in the morning,
or in small ei doses icpcatcd e\ciy half-horn
until its p«igati\e ettect is manifest These
doses are to be gnen daily until the stools lose
then dyseutenc charactei (ii\en in this way
its pmgatixo action is over befoie night
Trousseau was of opinion that the cure is the
more certain the gieatei the numbei of the
evacuations 1 quote this opinion to emphasise
the fact that no dangei is to bo appiehended
from fiee purgation, while the employment of
small nutating doses is vvoisc than useless I
conceive, howevci, that e\cessnc puigmg is not
without dangci Some recommend 60-gram
doses of Kpsom salts with 10 minims of dilute
sulphmic acid eveiy hour, until the bowels aic
freely opened, instead of sodium sulphate
Other puigatives may sometimes be pi cf cried
to salines Birch advises the use of castoi-oil
emulsion m the dysentenc affections of clnldicn,
after having cleaied out the bowel by a dose of
the common oil "In a couple of cla\s the
motions will lose their shiny, bloody, and curdy
appearance, and the case is resolved into one of
simple diarrhoea " It may be added that castoi
oil has been successfully used in the dysenteiy
of adults.
Use of Calomel — Calomel administered m
scruple doses twice or three times m twenty-
VOL II
four hours was at one time looked upon as a
specific in dysentery Trousseau «ind Bretonneau
tried this treatment with success m an cpidemy
at Touiaiue, but had to abandon it on account
of the salivation it occasioned in some subjects.
When given in these doses its action i* probably
chiefly evacuunt, like that of sulphate of sodium
ipecacuanha 01 silmes being safei, this method
of tieatment has been abandoned
In some epidemics calo*ncl given in model ate
doses las pioved sei \iceablc when ipecacuanha
and other lemedies have failed Niemever is of
opinion that in the higher grades of dysentery
one gram of calomel \\ith a quarter of a gram
of opium given every two hours is the best
tieatmeut His expoiieucc was derived from
the epidemic t)pc of the disease in Europe
Soheiibe, whose authonty caities gieat weight,
gives calomel m doses of 1 to 7 gi.uns ever\
iom or six. houis, obviating constipation, if
necessary, by an occasional dose of castor oil
lie his not found salivation to icsult \\heu so
given He adopted this tieatment m picfeience
to any othei m the dysentery of Japan, wheie
the disease is frequently epidemic and probably
of the diphtheritic type My expei lence of the
use oi calomel has been limited to cases which
pioved rebellious to ipecacuanha, and I have
given it m giam doses combined with a quarter
of a giainot opium, at hourly inteivals foi the
fust fewdoses, then at Inngei and longer intervals
When .1 case ot d}sentety h.is been treated with
ipecacuanha in large doses ftotit, the Icyi/miny,
and notvv ithstandmg passes into the seious
stage, peiseveiance in the use of ipecacuanha
is not likely to piovc of seivice, and I think
calomel should be at once lesortcd to If,
however, the case has not been treated from
the commencement, ipecacuanha should not be
abandoned because the disease passes into the
seious st.ige, but should be perscveied with
until it has had time to act Calomel should
ncithei be icsorted to piecipitately nor its use
delayed until the case is hopeless When the
fust <ases in an epidemy prove unamenable to
ipecacuanha it will not, of couise, bu nccessaiy
to begin every case with ipecacuanha or salines,
but if calomel pioves serviceable it should be
given iioui the beginning
1 IMAO found frequent fractional doses of
calomel or giey powdei of great senico m the
dysentery of children In some foi ins of bowel
complaint m ehildien, with frequent fclmiy,
bloody stools, a grain of the pel chloride of
mercuiy dissolved in ten ounces of water and
gncn, as limger letommcnds, in doses of 30 to
60 minims hourly, is veiy useful
When distinct paroxysms of malarial fever
accompany dysentery, qumiift is to be given
along w ith ipecacuanha or salines I f dysentery
symptoms intermit, the disease is to be treated
by full doses of quinine alone. We have men-
tioned a form of dysentery associated -with
29
450
DYSENTERY
malarial fever HI which ipecacuanha was useless,
but which yitlded to perchlonde of iron in largo
doses. This observation should be boiue in
mind, lu the form of dysentery m which the
caxram is chiefly imolved, and which is often
complicated with a severe type of malarial fevei,
the great prostration contra-mdicates the use
of ipecacuanha. Quinine and small puigativc
doses of castoi oil, with 20 to 30 minima ot oil
of turpentine, have seemed to me useful in this
form of the disease
When complicated with scoilmtus, the patient
should be put on milk diet A free use of lime
01 lemon juice is indicated Chapes, oranges,
or pomegianates may be given when lemons
cannot be procured IJael fimt gnen in the
form of sherbet is lecommended by Maclean
Solution of the penutrate of 11011, 01 oil of
turpentine, 15 to 20 minims in almond emulsion,
are. the best means of checking the hemorrhage
in this fonn of the disease
Pain and swelling of the joints .ire to be
treated by local applications of opium and
Iwlladonna, the affected joint v\ tapped in cotton-
wool and swathed with flannel
In scveic haemorrhage ausing fiom ciosion of
a large vessel, indicated by a copious disrhaigo
of clotted blood, astringent injections may be of
use if the seat ot the lesion is m the lectum or
sigmoid flexure, otherwise oui chief reliance
must be placed in hypodcimic injections of
ergotin The lull dose of 10 minims ol the
phaimaeoponalpiepaiation should be employed
In epidemic gangrenous rectitis injections
of lemon juice, suggested by native methods of
cure, should bo tiled, the bowels at the same
tune being acted on by gentle purgatives
The medicines chiefly employed m the tieat-
ment of amoebic dysentery aic calomel, salol,
and quinine given by the mouth, and solutions
of quinine, coirosive sublimate, and nitrate of
silver in enemata As an injection quinine is
used ot a strength of 1-1000 or 1-500 , corrosive
sublimate 1-5000, and mtiate of silvoi, 30
grains to a quait One or t\vo pints of these
solutions are to be injected three or four times
daily The results hitherto obtained from these
leniedies have been somewhat disappointing
CIIRONIC DYSIATKRY — A patient sufloring
from chronic dysentery contracted in the tropics
should be invalided home without delay If
the patient's return falls in winter, it is better,
if his cncumstances permit, that he should pass
a month or two on the Hi MCI a In any case,
groat care should be taken as regards clothing
Flannel underclothing and the use of an
alidommal belt should be insisted upon The
disease is one wlhch gives rise to great an.cmia
and debility , the diet, therefore, should be
nourishing and easily digested During the
periods of quiescence meat should be allowed
Graves remarks in one of his lectures that
cases of chronic dysentery he had mot with,
" which had obstinately resisted the most varied
lemcdics assiduously employed, got well after a
hbeial allowance ot meat was given , and the
hrst thing I should do," ho says, "when called
upon to treat a case of dysentery of long stand-
ing, would be to put my piticnt on a full meat
diet " During the acute or subacute exacerba-
tions the patient should bo put upon the diet
recommended for the acute disease Milk and
light farinaceous foods geneially answer best
during these exacerbations
Rest in bed should only be unjoined during
an cxaceibation Kvcreise, shoit ot fatigue, is
beneficial "When the patient is unable to walk,
carnage exeicise should betaken The chances
ot recoxeiy depend largely upon attention to
these details
Acute and subacute internment attacks aie
to be tieatod on the general principles applicable
to the acute disease Instead of the powdci of
ipecacuanha, an infusion of 100 grams each ot
ipecacuanha root and snnaiuba baik in ten
ounces of watei, given in ounce doses thiee or
foui times a day, is to be piefened When the
acute symptoms abate and the stools become
diaiiluval the dose is to bo led need, and a few
diops ot laudanum added Constipation is to
be obviated by the gentlest laxatives When,
on the othei hand, looseness is troublesome,
Dovet's powdei, suhey late of bismuth, and bael
fruit are the most trustworthy lemedies In-
jections of m ti ate of silvci or sulphate of
copper aie of value when no acute symptoms
.no piescnt, especially it chronic ulcers aie
present in the low ei part of the bowel A vv et
compress to the abdomen is often useful when
the bowel is congested or ulcciated Emollient
enemata and gentle pmgatives will be required
vvhcn'cicatiiual con ti actions impede the evacua-
tion ot the bowel
DySgeneslS.— An} moibid state of the
generative organs 01 lepioductive powers, or,
specially, hybudity m animals in which the
offspring aie sterile among themselves, but
possibly fertile with individuals of the original
laces
DySffeiJSla. — Impeifcct or depraved
taste. *SVe H\STEIUA (Sensory Disordeis) ,
PREdNANCY, AiJBfTIONS AND COMPLICATIONh
(Digestive and Sympathetic Disturbances)
DySldrOSlS. — Excessive secretion by the
sudoriparous glands and its effects on the skin ,
cheiropompholyx See SKIN, BACTERIOLOGY OP
(Chnropomphdyx or Dywchosis)
Dy Ski nesla.— Difficulty or impairment
of walking tiee LABOUR, INJURIES TO THE
GENERATIVE ORGANS (Pelvic Articulations).
DySkyesiS. — Morbid or complicated
pregnancy, or, specially, extra-uterine gestation.
DYSLALIA
451
DySlal la.— Difficult or indistinct speech
from defects in the speech-apparatus apart from
the cerebral portions of the same. Dyslogia is
difficulty oi speech due to a ccicbral lemon
Dyslexia. -Difficulty m leading, woid-
bhndness , dysanagnosia See APHASIA (Woid-
JBfandne**)
Dysmenorrhoea.— Pamful 01 difficult
men sti nation, the pain being sufficiently severe
to pi event the patirnt following her usual
avocation, and being felt either in the back
(sacralgia) 01 in one or other of the iliac
regions, or m tho hypogastimm and thighs
»SkeMENsruuAnoNT AND ITS DISORDERS (Dysmenor-
thwa), CuitBri\OB (Indication*, Dy*mcnorr/twa
and Stenlity) , (fiNBcorixri, DIAGNOSIS IN,
HYDROPATHY, MIITMSCHMERZ , MAMMARY
ULAN i>, DISEASES OP (Chtomc Lofsutar Mastitis) ,
UTLRUH, MALFORMATIONS, DISPLACEMENTS, Lv
FLAMMAHONH, AND TUMOURS , etc DvHmenoi-
ihoia may be congestive, endometntn, uliojtathic,
mjlammatot y, intei mediate (Mtttdkchrnerz),
niechanual, membranous, nervou*, neiuahfic,
oAstt ucti iv, ovarian, i/ieumahc (or yrntty),
sjMismodic, trttml, iiteiine, ot ixH/inal
Dysmimia. — Difhculty or inefficiency in
pi od i icing signs m lieu of speech 01 in illustiatiou
of it
Dysmnesla.— Dcfcettte memoiy
Defonmty , malfoima-
, TKRAIUJ^K.Y , etc
. — Muscular atony, as
in dysmyotonia (01 myotoma) congenita 01
Thomsen's disoahe
DySnUSia. — Weakness of mind 01 im-
pairment of intellect
DySOdia. — Fcotoi, especially irt'tid ex-
halations fiom the body, c </ ftuni the skin
in dyswlia cuUnea (bioinHliow)
DySOdontiasiS. — Difficult dentition
DySOOtOCla. — Ovan.ui dysmcnoi ihcoa
(Bariics) or difficult o\ ulation
tion See
. — Diminished 01 depiaved
appetite.
DySOSmla. — Impaired or diminished
sense of smell, 01 (sometimes) a fcetid
exhalation
DySOStOSlS. — Defective development of
a bone, eg tho cleido -cranial (?ywxto*i» of
Mano and Samton, m which there is absence
or imperfect formation of the clavicle with
associated cranial deformities (psevdo- hydro-
cephalus).
Dy 8 pare Un la. — Painful wexual con
nection, pain dunug coitus »Ste (XYNBGOLOU\,
DIAGNOSIS IN , VAGINA, DISORDERS ( Vayimnmu*)
Dyspepsia.— The morbid state m which
digestion is accompanied by pain 01 accomplished
with difficulty , numerous varieties have been
described, such as acid dys{)epHia, acute, alkaline,
atonic, bilious, bulimic, catarrhal, congestive,
climacteric, diabetic, duodenal, fermentative,
flatulent, functional, gaseous, gastro-mtestmal,
gouty, hepatic, hysteneal idiopathic, mflani-
matoiy, intestinal, imtatne, lientenc, muscular,
mivous, neuialgu, ovaiian, pancreatic, reflex,
renal, rheumatic, sah\ary, sympathetic, tabetic,
tobacco, urcvmic, and uterine dyspepsia See
rttw INDK.FSTION , AUDOMKV, CLINICAL INVESTI-
GA'iioN- ot (tivtHptomv) , ALCOHOL (Indications
m Dit/enifvuf Infancy ami Chtldho(*£), ATROPHY,
JKFINTII E (bvmjttams) , BREATH (M JDi/Kpepsui) ,
BRONCHI, BRONCHITIS (Etiolotjy, Piedi*po8ing
C'«M?f«), CHOLERA NOHIRAS (Diayuom^ Fer-
mentativt Dyipepwi) , (»AS'i«o-IxTES'irNAL DIS-
ORDERS OF INIANCY (Chtonic Vomiting) , GALL-
BLADDER AXD BILE Ducis, DIMKASES OF (Ad-
hesions) , H\I>KOPATIIY (Dyspepsia), HYPNOILSM
(Dyspepsia), LIVKR, DISEAHI-S OF (Cm hosts,
tfymptutm) , LniSH, PORTAL THROMBOSIS (tiymp-
toinv) , MILK (Therapeutic, Koumiss Cure) ,
NEPHRITIS (Renal Cm turns, Dyspepsia) , SPINE,
SURGICAL AJ.FEUTION.S OF (tiptnal Cane.*t Dwi-
ijnOSlt) , SlOMACH AND DUODENUM, J)lHEASES
OF (General IStiolof/y, General Symptomatology,
Special Xt/mptoniatoloijy, etc ) , TEEHI (Dental
Cane*), Tar ANY (Causation, (raitro-Jnteitinat
Affrrttims) , ToxiroLO(,Y (Lead - Poisoning,
Nymptomv) , UR;EAIIA (Chtonic, Symptoms,
Dii/t,i>ttve) , WAIBH (If aid Water, Dytpepsia)
See also ABDOMINAL
iesHure Symptoms), AORTA, THOR-
ACIC ANMJR\ SM (Si/mphmis, Dy»p/ui(/ia) , BRONCHI,
BRONCHIAL (JLANDH (Presmre-JK/ects) , Gix)h!so-
PHARYNGEAL NEHNE (Clinical Feature*) ,
II\STERIA (Dujfittve Diwden>, Dy*pluujia\ ,
LARYNX (Laiynyuil Phthit>it>) , LAIUNX, MALIG-
VAVP DISEASE OF (Symptom*), MEDIASTINUM
(Growt/is, Symptom*) , (ESOPHAGUS (Growths,
Symptoms), PHARYNX, KETRO- PHAIONGEAL
AUSCESS (Symptoms) , THYROID GLAND, MEDICAL
(Goitre, Symptoms) — Before lefcrrmg to the
vanous conditions that may induce dysphagia
01 difficulty of swallowing it is advisable to
bucfly consider the physiological processes
governing the act
The act consists of thiec stages — the fiist
being entncly voluntary, tho second partially
so, and the third entirely beyond the control of
the will The first stage consftts of tho passage
of the fcxxl as far back as the anterior arch of
the fauces, this being accomplished by the
intrinsic muscles of the tongue and muscles of
the check and mouth In the second stage the
452
DYSPHAG1A
tongue is retracted, the glottis is closed, the
larynx, soft palate, and pharynx are raised, and
the bolus of food is brought into the posterior
part of the pharynx During this stage the
food is prevented from passing into the nose by
the combined action of the tensoi and levator
palati , and the larynx is closed effectively both
at its upper and louer parts by the approxima-
tion of the tiue and false cords The third
stage is reached when the iood descends thiough
the grasp of the constrictors and enteis the
oesophagus — when by means of a twofold
movement, the longitudinal muscular hbies
being retracted and the circular hbies con-
tracted, the food is propelled into the stomach
The came* of dytpkagui will readily bo undei-
stood from a consideration of the stiuctures
involved in the process of noimal deglutition
These causes may be summaiised as follows —
(i.) Acute mflammatoiy conditions of the
tonsils, pharynx, and larynx In home cases
of sore throat the dysphagia is out of pio-
portion to the severity of the inflammation, a
condition probably due to interfeience \\ith the
action of the supeiioi constiictor muscle
(11 ) Involvement of these structures m the
course of a general disease, .is phthisis, syphilis,
or malignant disease
(in) Inflammatory and other conditions in
the neighborhood not directly associated with
these structures, e </ paiotitis, etc
(iv ) Stricture of the ci'sophagus, either of a
functional or organic natuie The most common
causes of the latter are malignant disease and
aneurysmal tumours Great care is necessary
in the measuics taken to diagnose this con-
dition Stnituie also results fiom ricatricial
contraction after the swallowing of vanouH
coriosive irritants
(v.) Paralytic conditions, e (/ bulbai paialysis,
post-diphtheritic paralysis, or the \cry late
stages of progressive muscular atiophy Any
organic lesion which mtei feres with the in-
tegrity of the centre in the medulla, or of the
efferent hbics passing to the muscles involved,
may induce dysphagia The difficulty in
swallowing obseived in many cases of general
asthenia shortly before death is duo to a geneial
failure of the \ital po\\cis, and is thus of a
paralytic nature In these cases, doubtless,
the failure is in great part dependent on a
lesion higher than the medulla
(\i) Functional Dysphagia — This consti-
tutes the most interesting group of all It
may be met with at any point of life, but is
most common in young adults, and in vety
neurotic children of from ten to thirteen years
old Like other manifestations of hysteria it
is more frequent/- in women The clinical pic-
ture varies considerably in accordance with the
greater or lesser development of other hysterical
symptoms The age of the patient, combined
with a study of the temperament, history, and
general state of tho patient, readily suffices to
distinguish this condition.
Dysphasla.— Difficulty of speech due
to ceiebral lesions
Dy 8ptlOnia. — Impoifect 01 difficult or
painful phonatiou or vocalisation, eg in cases
of clergyman's soic-thioat (when it is called
dytphonui cletnoiuni) or at pubeity (<ly aphonia
pulerum) , it may bo accompanied by stammer-
ing (speaker's ciamp ar dt/itphonia ipwtica) , and
in it tho voice may he i educed to a weak whisper
Dysphrasla.— Defective speech due to
defective intellect
Dysphren la.— Mental disorder
Dyspnoea.
»SW a/M ABDOMINAL ANEURISM (Pi enure Symp-
fowis) , AOHTA, THOUACU , ANKUIUSM (Xi/mptonw) ,
AWH\MA (DefitittUHi) , AsiiiMA (Nymjttomi) ;
BRONCHI, BRONCHI \L (»LAMK» (2'teu>me)t BIION-
(in, BRONCHITIS, (JHEsr, CLINICAL IN\ESTKJA-
TION OF -HIE (Inymtion) , G'liLouosib (fiyttijitomi) ,
DIAIUEIKS MELLITUN (Dm/vtic Conm, Symptoms),
HEART, MYOCARDIUM. AM> HNDOCHRDIUM (Hymp-
tomstfo/oyy) , HibiiutiA (#?w?</f?s of Revpira-
toty Org(w>) , Lu.v,, Tumturui osih 'OF (Symp-
tom*), LUNGS, KMPHYNEMA OF (tiymptonut) ,
Lu\<is, VASTUIAK DISORDERS (Pulmonary En*-
bohwi), MFDIASI-INUM (dhonftkst Symptoms),
PNEUMONIA (Chntral Features), STOMACH AND
DUODENUM, DrsB\biM OF (General Symptonuito-
loyy) > TABKH DORSALIS (Affections at Cjitntal
NetveA in) , THYMUS (tiuusD Ximjtle Ettlim
Dyipiuen), TuiKoin (JLAXD, MEDICAL
thafmu (Joitre), UHT-.MIA (C/nonic,
THK causes of dyspna»a \\ill bo icadily appreci-
ated on consideration of tho nemo -muscular
mechanism of respnation As this is described
in detail elsewhere, it is unnecessary to do more
than indicate that dining the inspiiatory phase,
air passes tlnough the nose, pharynx, larynx,
trachea, large and small bionchi, into tho lung
tissue proper, nhilo during expiration, the air
passes from the smallei bronchi through the
larger bronchi, laiyux, postenoi and anterior
nares, to the extenoi
Under normal circumstances this takes place
noiselessly, is unattended with distress or diffi-
culty of any kind, and has a frequency propor-
tionate to the age and sex of the individual
In all cases of embarrassed respiration, the cause
must be sought in some interference with the
neuro-museular mechanism of one or more parts
of the respiratory tract Hence tho impoitance
of making a systematic examination.
Inaptratory Dyspntxa may depend on obstruc-
tion m any part of the respiratoiy tract. The
diagnosis of the site of obstruction is frequently
readily determined by careful inspection of the
DYSPNCEA
453
patient and by analysis oi the points made out
on extra auscultation Thus, if there be any
obstruction in the nose 01 nasopharynx the
respiration is of a noisy diameter, usually de-
scribed as snuffling, and the voice is inoie or
less nasal in quality In cases of obstruction
duo to post-nasal growths (adenoids) the history
of the case <ind general physiognomy of the
patient will assist diagnosis If the pharynx
bo the seat of obstruction the breathing is
also maikedlv rough in character, the voice
is thick, and deglutition impaired When
the scut of obsti notion IB in the laiynx the
quality of the sound is markedly different, being
loud and stndulous in charactei, especially
mspnation
The dyspnoeas dependent upon obsti uctum in
the trachea or larger bronchi are similar, and
although respiration be noisy, it lacks the
stndulous charactei ot laryngcal obsti uction
The Causes of respiratoiy difficulty are here
usually enlaigemcnt of the bronchial or medias-
tmal glands from tubeiculous disease or malig-
nant growth and aneuiysm of the aoita The
raiei causes met \vith in cluldicn arc enlaigc-
ment oi the thymus gland oi abscess in the
postcnoi mediastinum, which may be secondary
to disease of thcdoisal Acrtebrte The diagnosis
of traeheal or bronchial dyspnoea can usually
be made aftei a careful study of the physical
signs in the t\\o sides oi the chest, special
attention being paid to a companson of the
amount of .111 entering each lung and to any
alterations in the quality of the. rcspnatory
murmur on the two sides Additional cMdonce
may also be obtained Irom the natuic of the
cough, especially if this is considered along \\ith
the results of laijngoscopic examination
Eapnaton/ Dyvpiuni — This is specially char-
acteristic of emphysema and asthma, and its
nature can readily be dctei mined on extra
auscultation In Homo cases it is larjngeal in
origin, as, for instance, when due to a pcdun-
culated subglottic tumour A few cases have
been recorded where pronounced expiratory
dyspnoea in young children has been found
post-mortem to be dependent upon enlargement
of the bronchial glands Such cases are excep-
tional, and while their explanation is not veiy
satisfactory the fact oi their occurrence should
be borne in mind The dtmjnov* of this form
of dyspnoea can usually bo arrived at from extra
auscultation, and can be confirmed by finding
the physical signs of emphysema and asthma
Reference ought also to be made to the \eiy
rare form of dyspnoea, both mspuatory and
expiratory, met with in cases of gross lesions of
the muscles, e q pscudo-hypertiophic paralysis,
and from certain injmics or diseases of the
apinal cord
A diagnosis can usually be armed at by a
careful investigation of each part of the respira-
tory tract This will in many cases include
anterior and posterior rhmoscopy, digital ex-
ploration of the natto-pharynx, the use of the
laryngoscope, and a careful physical examina-
tion of the chest, especially with a \ie\v of
detecting physical signs dependent on pressure
on the trachea, one or other bronchus, or other
structures at the root of one lung. A useful
point in differential diagnosis between laryngeal
and tracheal dyspnoea lies in the fact, that in
the former the laiynx makes much respiratory
movement, whilst in the latter it is station-
ary, howevei great the difficulty of breathing
may be
With regard to the sexenty of the dyspnoea
in any gi\en case, that depends not so much
on the degree of stenosis as on the rapidity
of its development Another question calling
ioi investigation is the permanent or inter-
mittent nature of the difficulty 11 the dyspncua
be laryngeal in site and constant, a paralytic
lesion is suggested, whereas if intermittent it
is suggestive of spasm , assistance in diagnosis
\\ ill also be obtained from a study of the voice.
The absence of voice impairment, however, does
not negative a paralytic lesion, as a bilateral
paralysis of the abductors would not be associ-
ated \\ith fiuy xoice distuibanoe
The ioregomg remarks apply paiticularly to
the usual run of cases where a definite obstruc-
tion exists to the inlet of an into the lungs or
outlet of an fiom the lungs Numerous other
cases are encountered whcic the dyspnoea is
laigcly pioduced or aggravated by a general
medical cause SIK!I as caidiac disease, renal
disease, asthma, emphysema, or acute lung
disease , and in these ailections we may find
the exaggerated type of dyspnoea kno\\n as
oithojmwi Hcic the attitude is one of intense
air hunger The patient assumes the position
winch allows fieest play to all the extraoidmary
muscles of respiration, and to this end ho must
be moie or less in the upright posture, the posi-
tion vaiving with the severity of the disease
We must also bear in mind that mental and
emotional disturbance may induce even in
healthy subjects disordered respiration, and a
tendency to this will be A cry much increased
it theie be present anything of the nature of
an organic cardiac lesion In this way may
possibly be explained the occurrence of attacks
of cardiac d>spnoja so frequently encountered
When dealing with dyspnoea associated with
general cardio-vasculai disturbance, the allied
s \mptoms of palpitation and thoracic pain may
be of assistance in diagnosis
Attention should also be drawn to those cases
of embarrassed respiration due to mechanical
disturbance fiom mtra-al)dommal causes, cither
of a direct mechanical, or oi a^eflex nature
Dyipntm in Children — The same causes arc
at work as in the adult, but here tempoiary
dyspnoea of a spasmodic nature due to spasm
of the glottis is much more frequent. There is
454
DYSPNCKA
also the relatively greater frequency of pressure
on the trachea or bronchi fioni <t tumour, glandu-
lar enlargement or abscess in the posterior medi-
astinum, and also antenoily from the thymus
gland, and in such cases the difficulties of respi-
ration permanently present are liable to occa-
sional cxacerbationb from bpasms of the glottis
The symptoms in such cases are noisy breath-
ing, metallic or croupy cough, the attacks of
dyspnoea being usually iioctumal, and associated
with other evidences of piessure
Another far-tor of importance in the dyspnoea
of children is the local muscular weakness of
the chest *«Ul present in rickets Here the
extraordinary muscles of inspiration arc readily
called into play, and in marked cases of the
inspiratory type, the movement of the musdes
of 'the aide nasi and the mdrawmg of the lower
intercostal spaces \\ith inspiration form along
wit;h other gcneial evidence a characteristic
picture
In older children the great frequency of ob-
struction due to adenoids should not be lost
sight of
— Defective or faulty secretion
of sain a
Dysspermatism.— Difficult or impei-
fect discharge of semen, t y from excessi\e erec-
tion of the penis (hy pet tonic dyHspormatism),
fiom phimosis (ptejmtial dyHspormatism), from
urethral obstruction, \\ant of force, epilepsy,
etc See SPROTUM AVD TESTICLE, DISEASES OF
(Sterility)
Dyssynodus or Dyssynusla. -
Difficulty in sexual connection
ia* Slo\i, lingering, and
painful death, as opposed to euthanasia
DystOCla.— Difficult, delayed, d.ingcious,
or complicated labour, as opposed to eiitocia ,
ftttal dystocia is difficult labour due to some
anomaly in the infant, in maternal dystocia the
cause is to bo found in the inothei
Dystopia.— Malposition or displacement
Dystrophy. — A morbid state charactei-
ised by defective nutrition, due sometimes to
disturbance of the tiophic nerve supply of the
parts (neurotic dysttophi/) tiee MUSCLES, DiH-
KASES OF THE (IdtOpatlllC MuvnlaT AttOphy Ot
Afyopathy)
DySUrla. — Difficult, painful, or incomplete
micturition tiee CHILDREN, CLINICAL EXAMINA-
TION OP (Urinary Nyitem, Dysinia) , GJONOR-
HiiaEAL INFECTION, PUERPERIUM, PHYSIOLOGY
(Regulation of Madder) , URINATION, DISORDERS
OP (Dysut id)
Ear.- -The diseases of the ear will be con-
sidered in the following articles The affec-
tions of the auditory nerve and labyrinth
have aheady been considered in vol i. pp. 327-
336 (yv)
1. Examination of . . 454
2. Ear, Local Anaesthetics 466
3. External Ear 466
4. Tympanic Membrane. 480
5. Middle Ear-
Acute Inflammation 482
Chronic Suppurative Inflammation 489
Chronic Non-Suppurative Inflam-
mation, etc 508
See a/so AUDITOR* NEKAR AND LABYRINTH,
BRAIN, PHYSIOLOGY (Circulation) , CHEEK, Fw-
SURE OK (Vat ictus), COUGH (" Eat -Coutjh ") ,
DEAFMUTISM , ECZEMA (Ear*) , GALVANIC (CAU-
TERY (Diseases of Eat), (iixwHO-PliAHYNOKAL
NERVE , (JouT (Ear) , HEADACHE (6f«wse«,
Reflet Imitation, Eat), HEARIXO, AmiPiriAii
AIDS TO. LARYNX, (-Hiioxir iM-EfiiVE DISEASES
(Latywjtal PttthiM^ Pain in Ear) , LIFE INSUR-
ANCE (Dwaw of fret voui Nyvtem, Middle Eat) t
LUNU, TuBERniLosis OF (Complications, Nervous,
Eat), LuN(is,VAsruLAHDisoRi)EiteOi' (Ptdnionaiy
Kmbolism, Middle Eat J)tsraw) , MALINUEIIINO
(Vat ictus, Autal) , MLMNOIUS, KIMDEMIC CERR-
BRO-SPINAL (Nymptomi, Eat), MENTAL DEFICI-
ENCY (Abnot nudities of Phywial Fmmation) ,
MUMPS OR EPIDEMIC I'ABOTIIIS (Complication*,
Actions of Eat), MUAHIS (Sftctnut, Aural),
NEPHRITIS (Renal Cm hows, Iliemoiihnqe into
TymjMinic Camty) , PHYSIOGNOMY AND EXPRES-
SION (Eat i) , PHYSIOLOGY, THE SENSES (Hear-
tnt/) , POST -MORTEM METHODS (Examination of
the Stain, Middle Em), PUHPURA (Werlhof*
Putpura, Jlleetiint/ J)MH Audi tot y Meatui) ,
RHEUMATISM, CHROMC (Clinical Ftatutei) ,
SCARLET FEVER (Complications, On;«ns of
Special *SV/is^, Ear) , SMN DISEASES OF THE
TROPICS (Jioih, Eiternat Eat) , SYPHILIS
(Secondary Nyphiln of tfte Eat, Tertiary
Syphilis of the Ear) , TB.EIH (Diseases of t/te
Ptdp, Pain in Eat), TERAIOLOOY (Ototefrftaly).
Ear, Examination of.
1 ANATOMY AND PHYSIOLOGY 455
2 SYMPTOMATOLOGY 437
(a) Dntutbances in Heat i in/ 457
(ft) Tinnitus Aututni 457
(c) Pain 457
(d) Vettii/o 457
(e) Discharg* from the Ear 457
3 INVEHHGATION OF THE FUNCTION OF
HEARING 458
4 OKJECIIVK EXAMINATION OF TUB EAR 460
(a) Technique 460
(b) The Tympanic Membrane 461
Normal Condition of 461
Pathological Conditions of . 462
5 EXAMINATION OF THE NOSE, NASO-
PlIARY>X, ETC 463
EAR, EXAMINATION OF
455
6. EXAMINATION OP THE EAR BY INFLA-
TION THROUGH THE EUSTACHFAN
TUUE 463
(1) VaUalvn't Ifetfwl . . .463
(2) Politzer's Method . . .463
(3) Inflation through the Ewstachian
Catfteter . . . .464
1. ANATOMY AND PHYSIOLOGY. — The anatomical
subdivision of the organ of hearing into three
party— the external, middle, and internal ear —
furnishes the clinician with a satisfactory basis
upon which to investigate the nature of the
affection in a case of deafness. Impairment in
hearing may be due to causes which exist in one
or more of these subdivisions or their adnexa,
and the examination of the ear practically re- j the naso-pharynx.
""
cuticular layer is continuous with the skin lining
the meatus ; the middle is fibrous, an extension
from the periosteum, and consists both of fibres
radiating from the centre towards the periphery
and also of circular fibres near the circumfer-
ence ; the inner mucous layer is a continuation
on to the deep surface of the membrane of the
mucosa lining the tympanic cavity. The blood-
vessels pass to the membrana tympani along
the handle of the malleus and thence radiate
outwards between its layers.
Under the term middle ear there must be in-
cluded the tympanic cavity, the Eustachian
tube, the mastoid antrum, and mastoid cells, all
of which are in direct communication with each
other and, through the Knstachian tube, with
The tympanum, tympanic cavity, drum, or
middle ear proper is a small irregular space
interposed between the external auditory meatus
solves itself into determining in which of them
the lesion exists. In estimating tho prognosis,
too, and in considering the amenability of the
affection to treatment, this anatomical
basis serves a useful purpose. For
these reasons, therefore, a brief sketch
of the anatomy of the ear and its more
intimate connections forms an essential
introduction to its clinical examina-
tion.
The external ear consists of the pinmi^
or auricle and the external auditory
meatus, the former collecting the air\
vibrations, the latter conducting them
inwards towards the tympanic mem-0
brane. The external auditory meatus
is about one inch and a quarter in
length, and has a general direction
from without forwards, inwards, up- Soction throilRh tho whole exteut of thfl m!ddlfl ear (Ban). A, Antrum ™«-
wards, and downwards, so that it is A-" " ' - - '
not a straight canal. It is made up
. ,
toid«um ; 13, mastoid cells ; C, inner surface of tympanic membranes at
lower end of nianubriurn : D. head of mallnuB ; E, body of incus ; O, COSKR for
part about half an inch long, which is
movable upon the deeper osseous por-
tion ; the latter measures about three-
quarters of an inch in length. A well-marked
angle or prominence exists in the antero-inferior
wall of the osseous meatus and is the chief cause
of the difficulty in the examination of the deeper
parts. Beyond this point the lumen of the canal
is again larger, and as its floor slopes downwards
towards the tympanic membrane, a recess or
sinus is formed in which foreign bodies may
lodge. The mobility of the cartilaginous meatus
is of the greatest assistance in the examination of
the car, as it permits of the canal being straight-
ened to a considerable extent. For this purpose
the auricle must bepulledupwardsaudbackwards.
The posterior wall of the osseous meatus has an
intimate relation with certain of the mastoid
cells, and sometimes when these cells arc dis-
eased perforation into the meatus occurs. The
external auditory meatus is closed at its inner
end by the tympanic membrane or drumhead,
which separates it from the middle ear. This
membrane is formed of three layers : the outer
. , ,
jugular bulb ; II, pyramidal partition of bone separating the cavity of the
,
tympanum from the autriim innstoideum ; below the letter H a portion of
the canal for the facial move i* drawn ; I, dura mater ; K, chonla tympani
nerve; L, tyinimiiie mouth of Eiifttechian tube: M, isthmua of Kustaehian
tube; N and P, cattilaRinoua walls of Euatachian tube; O, pharyngnal
month of Eustacliian tube. ' B
and the internal ear or labyrinth. It is tra-
versed from without inwards by a chain of
ossicles, the malleus, the incus, and the stapes.
The malleus or outermost bone is firmly attached
to the tympanic membrane; tho stapes, the
most internal of the three, is fixed through its
footplate to the membrane closing in the feuestra
ovalis, which lies above the promontory at the
upper and posterior part of the inner wall of the
tympanum. The incus is tho intermediate bone
in the chain. The sound vibrations taken up
by the membrana tympani are in this way con-
ducted across the cavity to the labyrinth. It
is necessary to draw attention to that part of
the middle ear which lies above the level of tho
upper margin of the tympanic membrane, speci-
ally designated under the twins attic or recessus
epitympanicus. This recess contains the head
of the malleus and the greater part of the incus.
The roof of the space is the tegmen tympani, a
thin layer of bone, while its outer wall is formed
456
EAR, EXAMINATION OK
partly by the ledge of bone which constitutes
the inner end of the roof of the external meatus,
and below that by the upper part of the tym-
panic membrane known as Shrapnell's membrane.
Certain ligaments attach these two ossicles to
tho walls of this recess, thus subdividing it, and
in tho event of suppuration occurring in it,
rendering drainage difficult, and the affection
therefore a more serious one. Such suppura-
tions are usually associated with a perforation
ill Shrapnell's membrane. The relations of the
facial nerve to the tympanic cavity are of great
importance, and will be studied in detail when
the operations upon the mastoid antrum are
under consideration. It should be borne in
mind here that, owing to an occasional con-
genital deficiency in the bony wall of the aque-
ductus Fallopii, facial paralysis may arise in the
course of an acute otitis media. In chronic
middle ear suppuration paralysis may follow
caries of the bony wall of the Fallopian canal.
The Ewitiifhi'in tube forms a direct com-
munication between the naso-phary-nx and the
tympanic cavity, opening into the latter an-
teriorly and superiorly. Its pharyngeal orifice
is situated on the external or lateral wall of the
naso-pharynx, on a level with, and immediately
V«rtirni section of the oxtornal meatiw, nionibrann lym-
pani, and tympanic; cavity (Politzer). u. Cellular
spams in tin1 .superior wall of thft mnatns, connected
with the middle ear; b, roof of tympanic cavity ; c,
inferior wall ; d, tympanic cavity ; t, mombrana tym-
ri ;/, head of the malleus ; g, handle of the malleus ;
IIICUH ; r, stape» ; *, canulin Fallopire ; I, foMwi
jiiKuUrin ; m, glandular uriflcm in the extenial meatus
(riKht par).
behind, the posterior end of the inferior turbin-
ated body. The direction of this orifice is down-
wards as well as inwards, while posteriorly and
superiorly its circumference presents a well-
marked prominence or cushion. Special refer-
om'o must be m:ido to the Eustaehiain tube,
owing ti» the iiiipurt-iit part which it plays both
in the physiology of hearing and in the pitho-
logy of deafness. It is essential for the proper
function of hearing that equal air-pressure
should bo maintained on both surfaces of the
tympanic membrane, so that tho membrane m.-iy
fully respond to the sound vibrations. This air
pressure is maintained on the inner surface.- of
the membrana tympani through the Kustachian
tube, the pharyngeal orifice of which opens
during swallowing by the action of the levator
palati and salpingo-pharyngcus muscles. Any
condition which tends to narrow or occlude the
tube interferes with its proper function. This
intimate anatomical association with the nose
and throat renders the tube liable to share in the
catarrhal affections of these regions, and it also
serves as a canal along which infective processes
may readily spread to the tympanum itself.
The tnastoid antrum, and cells lie behind the
tympanic cavity, and are in direct communica-
tion with it posteriorly and superiorly through a
short and somewhat irregularly-shaped passage,
the mucous membrane being directly continuous
from one cavity to the other. Posteriorly and
infcriorly tho antrum is separated from the
tympanum by a ridge of bone, so that its floor
lies below the level of the opening of communica-
tion ; for this reason, drainage of pus from the
antrum may be interfered with. ISoth the
tympanum and antrum are roofed in by a thin
plate of bone which separates them from the
middle cranial fossa. The mastoid cells vary in
their development, and for the most part lie
superficial to the antruin. The connections of
the middle car arc well shown in the above
figures.
Tlw Internd Ear or Labyrinth. — The third
division of the auditory apparatus lies in the
petrous temporal, internal to the tympanum, its
outer bony wall being formed by the inner wall
of the latter cavity. It consists of tlie osseous
and membranous labyrinths with the termina-
tions of the auditory nerve in the cochlea and
vestibule ; tho cochlcar fibres subserve the func-
tion of hearing, tho vestibular are concerned
with the maintenance of equilibrium. A more
detailed account of the labyrinth and .auditory
nerve will bo found under '• Auditory Nerve and
Labyrinth," vol. i. p. :i'27 ft *?y.
Clinical examination of the ear will be greatly
facilitated by grouping the different anatomical
parts above described under two heads : (1) The
sound-conducting apparatus ; (2) the sound-
perceiving apparatus. Hy the wund-Cfrnd-uctinrf
apparatus \\e mean the auricle, the external
auditory meatus, the membrana tympani, the
tympanum and chain of ossicles, including the
insertion of the footplate of the stapes in the
oval window. The sound-perceiving apparatus
consists of the terminations of the auditory
nerve in the cochlea, the nerve-trunk itself, the
various tracts in the brain, and the auditory
centre. When the lesion involves the conduct-
ing portion, it is frequently spoken of as pro-
ducing "obstructive deafness," and when the
perceiving portion is at fault, the term " nerve
deafness " is employed. It is essential that the
EAR, EXAMINATION OF
457
examination should be conducted along feucli
lines as will lead to the localisation of the affec-
tion in one 01 other, or m both, of those general
subdivisions
2 SYMPTOMATOLOGY — The chief symptoms
and signs m connection with disease of the ear
may be briefly stated to be (a) dislui banco in
hearing, (6) tinnitus, 01 subjective noises in the
ear , (c) pun, (</) veitigo 01 giddiness , and (e)
discharge from the ear
(a) Disturbances tn Ileaiinr/ — The onset of
deafness maybe rapid, or it ma} be moie 01 lews
gradual A Midden onset may result fiom <i
collection of \va\ in the e\tcin.il auditoiy mo.itus,
or it may be due to a Lib) i in thine effusion Jn
all cases of sudden deafness, mqmi} should be
made as to the previous existence ot defective
hearing If the onset is \eiy ui.ulual, it is
often difficult fen the patient to give any definite*
statement as to the exact time and mode of its
origin In all ( ases coming undei oWi \ation, |
an examination of both eais should be made, |
though the patient may complain of only one I
of them ('aieful testing may lev eai incipient
mischief vvht'ie none Mas suspected, and piog-
nosis may thciebj be influenced Tho moiohc-
quent (K'dirience oi the exanthemata in childien,
and the greatei tendency for acute mflaminatoix
pioccsses to pass fiom the naso-pharynx to the
middle ear, render that oigan more h<iblc to
inflammatory attacks in the joung In adult
life, on the othei hand, the (hionic (atanhal
affections of the tympanum an> inoic common,
while m advancing jears tho auditoiy neive
tends to icact less leadily to sound violations
Ilciedity undoubted h plavs apait in the causa-
tion of somi foims oi deafness, thus nee cssitatmg
a careful inqimyinto the famil> histoiy in such
cases The picsence 01 absence ot ceitam anom-
alies in healing should be inqune<l into, such .is
hearing better in a noise (jMiKinm* Wilhvi), or
double healing (dyJatiw*) The patient mav
complain th.it cei tarn sounds pi oduce almost a
paintul impression, hyjienKt/iewt aiomtua, but
this is a less common anomaly
(6) Tinmtu* AID mm oi Nubj*tnv jYiui<w* in
tlie Eat — Subjective sensations of sound aie
very frequently complained ot , these sounds
have no objective cause outside the body, and
they vary alike in then chaiaitei and their
intensity It should be home in mind that they
may be mtra-aural in origin and due to changes
of tension in the ear itself , again, they may be
reflex, the reflex cause being found in a diseased
tooth, or possibly excited by gastiic distmbancc,
lastly, and not mhcquentl), they are of vascular
origin, and may be due to changes m the condi-
tion of the walls of the blood-vessels, as in
Bnght's disease, to changes in the cii dilation in
heart disease, and to changes in the quality of
the blood itself, as in ancemia It is sufficient
merely to indicate these points here, so that the
attention of the aurist may not be confined
entirely to the ear itself in the elucidation and
treatment of this most disagreeable complaint
(c) 1'atn — Pain is a maiked symptom in
acute inflammations of the external and middle
eai , when complained of in association with
chrome suppuration of the latter cavity it lie-
comes a svmptom of considciable gravitv It
must not be forgotten that pain niaj be leieried
to tho ear in association vv ith carious teeth ,
objective examination of the ear and ot the teeth
will, os a mle, cleat up this point Pain aggia-
vatcd on moving the jaw, on pleasure upon the
tia«rus, or on pulling the auucle suggests the
presence of a meatal inflammation , on the othei
hand, if deep-seated, intermittent in character,
being w 01 seat night, and aggiavatcd b} blowing
the nose and coughing, it is more sjmptomatio
oi an acute otitis media When pain is associ-
ated with dwchaige fiom the ear, attention
should be paid to the condition oi the mastoid
piocess, and its presence maj be elicited by
careful pie^sme upon the bone
(tl) }'ritnfnot (tuMma* — Thissvmptom may
be sudden and seven*, as m the.typical Mtiuit»refH
disease of the labyrinth, 01 it mav be veiy hhght
m character Anything which will alter the
tension of the labjiinthmc fluid ni.i) cause some
degiee of veitigo, hence the piessuic ot wax
upon the tympanic mem Inane, an mdtawn con-
dition of tin1 membrane, 01 the pieseuce of fluid
in the t}inpamc <avit} mav exeit sufficient
picssmc thiongh the chain of ossicles upon the
tenestra ovahs as to im lease the tension of that
fluid (tiddiuess pi eroded b} nausea may be
due to gastric disturbances, giddiness followed
b^ nausea suggests, on the contian, its otitic
01 ijrm
<y) /Jot/irr/r/r ftom the Em — Dischaigc fiom
the oai xaiies in its charactei , it may be thin
and seious, often containing Hakes of epithelium,
as in the ec/ematous conditions of the meatus ,
it ma^ be muco-puiuleiit and stimgy, or puru-
lent and thick , sometimes it is tinned with
blood, an appcaiancc \\lmh should always sug-
irest the piesence of ^lanulations oi polypi Dis-
(haige fiom the e.u mav be meatal in on^in, as
in eczema 01 in a( ute inflammatory ( onditions,
but as a mle its souice lies m the middle eai,
and it (hams thiongh a pertoiation in tho t}iu-
pamc* membiane It may l>e extiemely ottensive
in chaiactci, and in every case of aural discharge
the examiner should make it a loutine practice
to smell the speculum on its vuthdiavval The
iojtoi which so fie<]iicntl^ <ic(ompames a chronic
middle eai suppuration is pathognomomc of that
condition Ihc patient's statement as to the
cessation of an auial discharge should never be
accepted until a careful examination of the ear
has been made 1 1 the cxa»iincr should fail to
satisfy himself of its presence by mere inspection
through the speculum, he should not fail to
introduce into the bottom of the external mcatus
a wick of absoibcnt wool, and on its withdrawal
458
EAR, EXAMINATION OF
examine it closely for any indication of moistuie
or factor
3 INVESTIGATION or ins FUNCTION OF HEAH-
INO. — We have already indicated in the anatomi-
cal sketch of the ear that impairment of hearing
may be due to causes existing in the sound-
conducting or sound-perceiving appaiatus, 01 in
both While an objective examination of the
ear will assist in determining the site (and
nature) of the lesion in the former, the possible
existence oi a lubj rinthmc attection can only be
accurately judged by carefully testing the heai-
mg function Hence such tents sei ve the double
puiposc of estimating not only the degree of
deafness that may be present, but also of local-
ising the seat of its oiii>m
Sound sensations may teach the nuditoiy
neivc terminations through t\vo channels, the
exteinal auditory meatus and chain of ossicles,
/ e by air- conduction, and thiough the bones
of the skull, i e by bone-conduction Certain
simple method^ are employed for testing audi-
tion thiough both these channels , these aio
the \vatch, the voue, and the t unmg fork
While cairying out this pait ot the examination
care must be taken to eliminate e\eiy source of
erior, it reliable obsci rations are to be made
It is very necessaiy that the diftVient tests be
applied before any treatment is earned out, and
that the lesults obtained by these tests be at
once caicfully noted in writing , the date of the
first as well as ot latei examinations should be
registered, and the suriounding conditions on
subsequent occasions should be as nearly as
possible similar to those which existed in the
first instance The same test apparatus should
be again employed In cvety case the hearing
power of both ears should be ascertained,
although the patient may only complain of
deafness in one of them
Before proceeding to apply the various tests
it is advisable to introduce the speculum and
ascertain whethoi any obbti action exists in the
exteinal auditory meatus of the natuie of wax,
etc , so that a needless icpetition ot the tests
maybe a\oidcd by a preliminary removal of the
obstruction
(n) T/ie Wntih Tett —The distance at which
the tick of any given watch is heard by the
normal eai is picviously ascertained by ex-
periment upon a numbei of healthy ears, so
that a definite staudaid foi comparison is thus
piovided This distance may be recorded in
inches
Mit/ttjd — The patient is placed with one eai
directed towards the examiner, while the othei
is closed by the introduction of a finger. The
eyes may \\ith advantage bo closed, a pre-
caution which is especially necessaiy m the case
of children The examiner, holding a yaid
measure m one hand, gradually bungs the
watch towards the ear under examination from
a point outside the langc at which the tick is
perceived by a normal ear Oaie should be
taken that the watch docs not touch the foot*
rule if the latter is in contact with the bones of
the head. The patient is directed to state
at once when the tick becomes audible , after
two or three control expeiimcnts have been
made, the distance is noted and the measure-
ment registeiod in inches This may be ex-
pi esscd m terms ot afiaction, whose denominator
repiesents the noimal hearing distance of the
watch, cq 30 inches, while the numerator
expi esses the distance in any given case, c </
5 , i v -,V If the watch bo heard only on
contact 01 on pressure upon the skull, it may
be expiessed as 3pn, while if the tick is not
peiceived at all, it may be legistcred as j°ff
The same proceduie is then carried out with
the other ear
(b) The Voite Te^t — In estimating the
healing distance by means oi the human voice,
the whispei and the oiduuiy conversational
\oifc aie employed , these may be variously
modified, so that low and loud whisper, low,
oidmaiy conveisational, and raised voice may
be used as the examiner sees fit The result is
lecoided in feet
Jfet/itMf — The patient i cumins seated side-
ways as befoie, it being \eiy necessary that the
movements of the exanunci's lips should not be
obsen ed , the eai ot the opposite side is again
closed with the fmgei The observer retires
acioss the room, ha\mg dnected the patient to
tcpeat at once the woids which he succeeds in
healing If he should fail to heai anything at
this distance, the exammei giadually appioaches
until he comes within hearing distance This
is carried out both with the whispeung and
with the oidinaiy com crsational voice The
othei eai is then examined and the results are
again legwteied in feet With legard to the
woids used for this pmposc, it is perhaps
advisable to employ single woids, the patient
in each instance repeating them when heaid
When sentences aie spoken oi questions asked,
the peiception of one or two woids only may
give the key to the whole, and in this way a
guess may piovc coiiect and a false estimate
be thus obtained. The numerals supply suit-
able syllables if too much repetition be avoided
The necessity of maintaining a uniform pitch
m the use both of the whispering and of the
speaking voice is evident, and facility m acqimmg
this will be obtained by piactice
Heunnq TVfcfs in Children — In children it
is often difficult, and in the very young even
impossible, to obtain satisfactory answers either
to the watch or voice tests In the majority of
cases the foimer is quite unreliable It may
sometimes suit all practical purposes to ask a
few simple questions in ordinary tones and note
whether they aie responded to. On the other
hand, it may be necessary to instruct the
parents as to what is wanted, so that they may
EAR, EXAMINATION OF
450
examine the child at home in the absence of
any stranger. In the case of very deaf children,
for the purpose of ascertaining whether any
sound perception exists at all, such tests as
clapping of the hands, the ringing of a bell,
and blowing of <i whistle may be employed
The source of such sounds must not be observed
by the child, \vhose attention Hhould be engaged,
and whose expression Hhould be watched by the
parent or attendant At the same time no
current of air pioducod by those acts should
fall upon the patient's head 01 face, noi must
any mechanical vibration leach him, as a source
of fallacy is thus introduced
(c) The Tumn<j-Forh — It is unnecessary to
enter fully into a considei.it ion of the tunmg-
fork tests, aw a detailed description has aheady
been given under "Auditory Nerve and Laby-
rinth," vol i p 327 It will suffice here to
briefly recapitulate the difleient points The
•vibrations of a tuning-foik aie conducted to
the nerve- endings m the labyrinth, through
the* external auditory meatus and chain of
ossicles, and alno thtouirh the cranial liones
The toimer is Hjwken of .is "an -conduction,"
the latter as " bone-c (induction" of tumng-foik
violations In a normal ear these vibrations
are some\\hat better heatd by air-conduct ion
It m a tfait pei son the vibrations of a tuning-
folk are pctceived more loudly when the folk
is applied to the skull than when it is held m
front oi the ear, "obstructive deafness" 01 a
lesion in the sound-conchu ting app.uatus is
indicated, m other woids, theie is "increased
bone-conduct ion " On the othei hand, if the
vihiations art* beltei beaid in the doai ear \\hen
the fork rt held in itont of the meatus, "nei\e
deafness" is indicated, if thcic is "diminished
bcme-condiution " These facts mnv be mcne
briefly oxpi essed as bone-c onduction + ( 1 M !> A( " )
or bone-conduction - (A(1>BC) (Webei's test)
In a noinw/ eat when a Mbiatmg tuning-fork
is placed on the mastoid pine ess and kept in
contact until the sounds aie no longet hoaid,
they again become audible when the folk is
held opposite the meatus (K nine's test positive)
It in a deaf eai the tuning-foik, aftei ceasing to
be heatd on the mastoid, be held opposite the
meatus and is not again heard, Hume is nega-
tive, and a lesion m the sound-conducting
apparatus is indicated On the othei hand, if in
a deaf ear the tuniug-foik Mbrations aie again
heard in front of the meatus, Kmne is positive,
and a lesion of the sound-peiceivnig apparatus
is indicated These iacts may be moie briefly
expressed as Rmne — and liinue + (iardinet
Browne's and Schwabach's tests may be useful
as supplementary tests
Other Tetfi occavorutlly employed — (Uidmei
Browne's — In the normal, if the base of a
medium \ibratmg tuning-foik is held on the
mastoid process, it ceases to be heard at the
same time that a tiaincd fingei and thumb
cease to feel the vibrations In middle eai
disease the patient will hear the sound some
time after the observer has ceased to feel the
vibrations In mtcinal ear affections the patient
ceases to hear the fork some seconds before the
\ibrations have ceased to be felt
Schwabach's — In using this test the observer
compares his own bone-conduction, which must
be noimal, \\ith that of the patient It the
\ibratmg tuning-folk placed on the mastoid
process of the patient has ceased to be heard
by him, but is still heard when placed on the
mastoid pine ess of the ohser\er, labyrinthine
disease is indicated , on th« othei hand, if the
patient heuis the folk after the obsener has
ceased to do so, the existence ^f middle or
external enr disease is suggested
Te«f\ fftrJ{<tn(/pof Tone Ilearuu/ in Laltyunth-
ine Uiwiw — In addition to tho e facts already
elicited bj the use of the tuning-fork, iurther
information can be obtained by testing the
appreciation oi the eai ioi sounds of diileient
pitch It is generally admitted that when the
impanmcnt of hearing is most marked for high
note's — the low tones being rclatnely well
heard — the lab} unth and somid- perceiving
appaiatus is at fault On the othei hand,
when the impanment of heating is most marked
for low notes — the high tones being telatively
well heard the lesion is piobablv to be found
m the sound-conducting apparatus Foi this
purpose a series of tuning folks of xaiung pitch
may be used, oi one fork piouded with metal
clamps, which ma\ be mo\cd up and down the
hmbs, tin* decpei tones being ptoduced when
the clamps ate fixed towatds the free ends of
the* fork and vice IWMI By the use of (ialton's
whistle, similat variations m pitch ate obtained ,
care should be taken that the patient docs not
confuse the blowing sound ptoduccd by the
whistle with the tiue whistling note In the
absence of such mstt uments as these, an attempt
may be made to foim some estimate of the
relative power of appieciatmg high and low
tones by the use of letters of different pitch
Au 01 ding to Wolfe, 11 lepiesents a sound of
veiy low pitch, S, on the othei hand, is of high
pitch In inteiiul eat deafness the voice may
lie hcatd iclativcly mote distinctly than the
lughci note of the natch tick Yaiious musical
instruments may also be used foi testing gaps
m the lange of healing
Simulated Denfne^ — Various deuces are
employed for the detection of feigned deafness
If the hearing in the affected ear is said to be
unjHiiietl, the patient should be caiefully tested
when blindfold If total deafness, on the other
hand, be feigned in one cat, the ear pieces of a
bmauial stethoscope should be introduced into
the patient's ears, the end nisei ted into the ear
in which heating is said to be present having
been pic\iously plugged with a piece of wood.
If the patient repeats words which are whispered
460
BAR, EXAMINATION OF
into the cup-shaped end of the btethoscope,
the true nature of the condition becomes
evident. Valuable information may be obtained
by the use of the tuning-fork if the patient is
ignorant of the true results of the different tests
When complete bilateral deafness is feigned, the
diagnosis becomes moie difficult, and it may
be necessary to adopt the ruse of attempting to
awaken the malingerer from bleep
4. OBJECTIVE KXAMINAHON OF THE EAU —
Before proceeding to examine the deeper paits
of the external auditory meutus and the tym-
panic mcmbiane, the suigeon should make a
simple inspection of the auricle and adjacent
parts, because much useful information may be
obtained b} n prelimiuaiy examination of this
kind The patient's featuics may piesent the
character so frequently spoken oi as the " ade-
noid facies," the result oi nasal obstruction , or
the existence of facial paralysis may be detected
oil one 01 both sides Knlaigcment of the
glands ui trout of, below, oi behind the auricle
should bo noted and their i-ondition more
exactly determined by laicful p.\lpation In
children an otorrhou associated with enlarged
lymphatic glands and facial paralysis strongly
suggests the tubercular natuic of the affection
If there is an} undue prominence ot the auncle
the cause should be investigated Redness of
the skin, oedema and spelling over the mastoid
process, and the piescncc of a sinus 01 ucatux
in the same region should not be o\ci looked,
and the significance of such signs must be duly
estimated Malformations of the auricle and
tumours may present themselves, \\htlu eczema
confined to the pinna or in association with a
like condition of the auditoiy mcatus may bo
readily detected on inspection It must not bo
forgotten that with suitable illumination the
outer portion of the mcatus can bo examined
without the intioduction of the speculum
Such an examination, aided by pulling the
auricle upwaids and buck* aids and by gently
drawing the trains forwards, should be carried
out as a loutmc piactice In this way the
patient may be saved needless pain or dis-
comfort, such as might bo caused by the in-
set turn of the speculum into an inflamed
mcatus , at the same time boils, ec/ema, pus,
and even the presence ot a poh pus or plug of
wax can be in this way icadily detected
Examination with, the Aid of the Awal
Speculum — Source of Ltyht — Good illumination
is essential foi a proper examination of the
car The doepoi paits of the external auditory
meatus and the tympanic membrane are most
satisfactory examined by teflected hyht, t e by
the indirect method The source of the light
will vaiy accotding ^o circumstances , if blight
daylight can be obtained, no better source of
illumination need be wished foi. The actual
rays of the sun may piove somewhat trying to
the observer's eye, and care must be taken to
prevent the rays falling directly into the ear
from a concave reflector, otherwise the parts
may be burnt. Of the artificial sources of
light, mention may be made of the Welsbach
incandescent gas fiom an argand burner, the
electric and oxyhydrogen light A simple oil
lamp or candle may prove quite satisfactoiy in
default of any other means
The jRefleitot — The small aural icflector in
common use has a diameter of about three
inches and a focal distance of five inches, and is
perforated with a small central aperture It
should not only bo piovided with a handle, but
should be capable of being easily adapted to a
foiehead band or spectacle frame, so as thus
to leave both hands of the examine! free if
nccessaiy
The Ain<tl tij>ecu/iiin — XumeioiiH foims of
specula have been mtioduccd, and it would be
useless to enumerate the varieties hcic The
operator soon accustoms himself to the use of
one tnim, which he leanw to regaidas supenoi
to .my othci Only the simple tubular
speculum should be employed A dilating
speculum foi the car has no ad\ antages, and
only causes the patient pain and discomioit
A set ot specula consists ot fom , the sihci
msti union ts luue this advantage, th.it they can
be boiled , vulcanite specula ,'iie usctul when
caustics aie applied to the ear
(<r) 7a/t»ij(/*/fj of tin E Hi munition — A satis-
factoiy examination ot the deeper paits of the
car depends largely upon good illumination and
coircct manipulation of the pinna and speculum
The patient is seated with the ear to be
examined tinned away fiom the souice of light,
his head being slightly inclined towards the
opposite shoulder The suigeon, sitting 01
standing, holds the reflector lightly in one
hand, in the iii>ht hand for the light ear, in
the left hand foi the left, placing the upper
rnaigin against his forehead, and tilting it to
the angle lequncd for throwing the best pos-
sible light upon the parts His eye, the light
01 left as the case may be, must be placed
directly behind the cential aperture of the
minor A medium-sued speculum, held by its
margin between the index finger and thumb of
the othei hand, is now gently inserted into tho
cartilaginous meutus, and at the same time the
upper part of the pinna is grasped between the
middle and ring fingers of the same hand and
pulled upwards and backwards, thus rendering
the canal as straight as possible. The speculum
can now be insinuated a little farther, slight
rotation assisting the moxement, due care, how-
e\er, being taken that it is not inserted as far
as the bony mcatus As a complete view of the
whole tympanic membrane is not always ob-
tained in one field, tho outer end of the speculum
should be moved backwards, forwards, upwards,
and downwards, so that the various areas may
bio brought into view The patient is then
EAR, EXAMINATION OF
461
turned round and the other ear is examir '
a similar manner. In every case both ears
should be inspected, although only one may be
complained of. Certain preliminary difficulties
present themselves, but a little practice soon
enables the observer to obtain the maximum
amount of light, to inspect the parts through
the central aperture of the mirror, and to
straighten the auditory ineatns by pulling the
pinna sufficiently upwards and backwards.
Should wax or other cause of obstruction in-
terfere with the examination of the deeper
parts, the car should be syringed. If the canal
is :too narrow to admit of the insertion of a
medium-sized speculum, a smaller one may be
substituted, but the routine use of small
specula should be avoided, as the field is thus
curtailed and the amount of light considerably
reduced. If it is thought desirable to remove
a piece of wax or epithelial flakes with the car
forceps, or should it be necessary to use the
probe, the reflector must be attached to the
forehead band or spectacle frame, so that the
left hand becomes free to manipulate the
speculum and pinna, while the forceps or probe
is held in the right. Occasionally a reflex
cough is induced by the insertion of the
speculum into the meatns.
(It) Tfie. Tympanic Membrane. — The tympanic
mernbnuic (membrana tymjmni) or drumhead is
of a bluish-grey colour with a somewhat polished
surface, presenting a distinct contrast both in
colour and apparently in consistence to the
white skin lining the deeper part of the external
rncatus. Concave as a whole, on its outer or
meatal surface it occupies an oblique plane, so
that the Superior and posterior parts lie nearer
the observer's eye than the anterior and inferior.
The handle of the malleus (manubrium mallei)
is visible on the outer surface of the membrane
as a slender ridge of a whitish-yellow colour
traversing the mem-
brane from above down-
wards and backwards
to a point a little below
the centre. At the
upper end of the handle
there is a distinct white
knob -like projection,
Ouler aspect or fight tympanic the short Jfocess of the
' malleus. The lower
lld' on the othur hand'
flaccid* ; /, posterior fold ; g, forms a slight cxpan-
long proc.A88 of iucuH Bhining H:mi nft(>n rliatiiicrlv
through the membrane (Barr). 81°" , olu" distinctly
visible, which is situ-
ated at the urnbo or point of greatest concavity of
the membrane. Passing downwards and forwards
from the umbo towards the circumference of the
drumhead may be seen the triangular bright spot
arconeof light, with its base towards the periphery.
This triangle of light often forms a conspicuous
landmark in the field of vision, but it is subject
to considerable alterations both in shape and
-veil on healthy membranes ; as it is pro-
duced by the reflection of the rays of light from
that part, and as its shape is dependent upon
the plane of obliquity of the membrane, very
slight changes may influence its shape and size.
If the examination be now directed above the
short process of the malleus, Shrajmell's mem-
brane (membrana fiaccida) comes into view,
differing structurally from the rest of the mem-
brane in that the middle fibrous layer is absent.
An anatomical perforation may exist in this
area. Passhg forwards and backwards from
the short process of the malleus to the periphery
are seen two elevations or folds of membrane,
the anterior ani posterior fold*. They are
cause'! by tho projection of the short process,
and with it constitute the lower limit of Shrap-
nell'rt membrane. Sometimes in normal condi-
tions the long process of the incus may be seen
through the membrane behind the handle of
the malleus, and running more or less parallel
to it. If the membrane be very transparent or
atrophied, other intra-tympanic structures may
become visible, such as the incus-stapes joint,
and even the chorda tympani nerve. For
descriptive purposes the membrane may be
subdivided as follows : — A primary division into
two by an imaginary line prolonging the handle
of the malleus downwards to the periphery and
forming a larger posterior and a smaller anterior
segment; the subdivision of each of these
segments again by a line bisecting the former
one, so that four divisions result, an anterior
superior, anterior inferior, posterior superior,
and posterior inferior quadrant. The various
lesions may be located and described as existing
in one or more of these areas.
The mobility of tfa tympanic membrane should
be tested. This may be done in one or more of
the following ways: -(a) By inflation of air
through the Eustachian tube by the method of
Valsalva, (ft) by inflation by Politzer's method
or by means of the Eustachian catheter, and
(c) by the use of Siegle's speculum. Inflation
of the tympanum will be described presently ;
it is only necessary to say here that the
tympanic membrane must be carefully observed
through the speculum during the process of
inflation, and the presence or absence of move-
ment noted. Should Folitzer's method or the
Eustachian catheter be used, an assistant is
required to carry out the inflation.
Siegle's pneumatic speculum somewhat re-
sembles a large car speculum, but its expanded
end is covered with a piece of glass placed
obliquely, while to an aperture in one side of it
there is attached a tube and indiarubber ball.
The narrow extremity of this speculum must
be made to accurately fit the external auditory
mcatus so that the latter along with the
speculum forms an air-tight cavity. The
examiner with the reflector on his forehead
observes the tympanic membrane, while he
462
EAR, EXAMINATION OF
alteinately compresses and relaxes tho india-
rubbcr ball, this compression and exhaustion
of the air column in the mcatus causes tho
different mobile parts of tho membiano to
move. By careful obseivation the actual move-
ments of tho tympanic membrane may bo seen,
or a change m its position may be indicated by
the appearance in one or moie situations of
bright i ejecting six>ts If the membrane moves
outwards on inflation, but almost at once sinks
back again, although tho patient has not
swallowed, it is probable that adhesions exist
between it and the inner wall of the tympanum
PatMotjical Condition* of the Ti/mjtanu Afem-
brane — Variations in Colour — The tympanic
membrane may vary to some extent in its
coloui, polish, and transparency consistently
with a noi mal standaid of healing, the appeal -
anccs being slightly modified by the intra-
tympanic structures which may bo seen thiough
it Behind tho umbo a whitish area may be
due to the promontory on tho inner wall of the
tympanum, while behind the handle of the
malleus the long piocess of the incus or the
incus -stapes joint may be visible through
the membrane as gieyish-wlute stntctures, in
tho posterior mfeiior quadrant a dark aiea may
signify the niche leading to the fenestia lotuuda
In the moic advanced yeais of lite there is a
tendency for the membrane to become \vhitei
and less polished Such normal conditions,
however, may be exaggerated and have a pitho-
logical significance Thus in geneial atrophy of
the memluine, tho incus, stapes, .and promontory
may become \ery apparent Ii circumsc nbod
atrophic patches exist, they appear as daik
transpaient areas which arc not distinctly
demarcated fiom the surrounding membiane ,
on inflation, or when seen through Siegle's
speculum, the atrophic aieas show gieat mobility,
and may bulge trecly into tho meatus A
cicatnjc, the evidonco of a healed peiforation,
usually presents itself as a dark transparent
area, often difficult to distinguish from a patch
of atrophy, but it is more shaiply defined from
tho surrounding healthy membrane than is the
atrophied portion Owing to the transpaiency
of the cicatnx, it may only be possible to
difteientiate it from a peiforation by observing
tho result of rarefaction of the air in the meatus
with Siegle's speculum , if a cicatnx be present,
it will bo seen to move outwards when tho
mdiarubbei ball is relaxed , in the cape of the
peiforation no movement is observed TJucken-
inq of the membiane varying in degree and
extent may show itself in the form of opaque
patches, 01 the whole membrane may be more
or less white and without its natural polish
Caicaieous deposits may form in its layers and
be evident as white chalky areas, sometimes of
a crescentic shape If touched with tho prol>e
their calcareous nature is at once demonstrated.
The inflamed membiane presents different appeal -
ances, according to the degree and stage of the
inflammatory process The congestion may be
limited to the vessels about tho handle of the
malleus and its short piocess, or they may bo
seen radiating outwards across the membrane
as a number of inegular pink lines On the
other hand, tho whole membiano and tho dee]>er
part of the osseous meatus may present the
appearance of deeply inflamed skin Tho
piesence of fluid m t/te tympanum, may be in-
dicated by a yellow appearance of the lower
paitof tho membiane, tho discoloration being
bounded above by a daik line sti etching acioss
tho diumhead Tho membrane may be bulged
outwards into the moatus either in whole or
pait by exudation behind it, so that it occupies
a plane neaiei to the observer's eye than
th.it which the normal membrane has It is
impoitant to learn to appreciate these alter a-
tions in the plane of the tympanic membiane
The iwbawn membrane so frequently met with
is characterised by the prominence of the shoit
piocess of tho malleus and of the antenor and
posterior folds , tho handle oi tho malleus is
diawn backwards and inwaids to a varying
dej-iee so that it becomes foi eshortonod, and in
some cases assumes an almost horizontal position,
the cone of light may entirely disappear or be
visible merely as one or more small reflecting
spots of light The membrane as a whole lies
on .1 dcepei piano than normal, and presents a
moio distinctly concave appearance A perfora-
tion may be present in the tympanic membiane ,
as a rule it is single, but sometimes more than
one exists, they vaiy in &i7e fiom a small pin
head to a complete destruction of the whole
membrane A portion of, or nearly «tho whole
of, the innci \vall of the tympanum may be
\isiblo thiough tho perforation, and experience
will lead tho observer to appreciate the dis-
tinction between the plane oi tho membrane
and the dcepei plane of the inner wall , in these
cases f uither assistance in diagnosis may be
domed from the use of the piobe, the haid
consistence of the bony wall forming a distinct
contrast to the more yielding nature of the
membrane itseli Tho diagnosis of a pcifoiation
associated with fluid in the tympanum may be
fiuthei assisted by inspecting the car during in-
flation, when bubbles oi air mixed with secretion
may be observed When the perf oration is very
minute it may be impossible to see it, but one
sign which is almost pathoguomomc of the con-
dition is the presence of one or peihaps more
pulsating spots of light, distinctly visible on
inspection The secretion in contact with tho
inflamed mucous lining of the tympanic cavity
rises and falls \vith oveiy heart-beat, it is very
doubtful if this phenomenon be \ isible to the eye
when tho membrane is intact Gtanulaturtw
may be recognised as red fleshy masses varying
m size , they are of soft consistence and readily
bleed when touched } when large they constitute
EAR, EXAMINATION OF
463
aural polypi, recognised by then closci piovnnity
to the speculum, their mobility, and the fact
that the prolxj may bo passed round them. In
all caHCB of (inspected perforation the precaution
should bo taken of smelling the speculum , the
presence of a fcotid odour, so significant of
chionic middle ear suppuiatiou, and therefore of
an existing perioi.ition, is a, valuable diagnostic
aid In these cases another speculum should be
employed for the examination of the oppohite
eai, otherwise there IH room ioi a possible fallacy
in the Hecond instance
5 EXAMINATION OF TUB NOSE, NASO-T'HAIU NX,
PHAIUJHX, AND FAUCES -- Owing to the intimate
anatomical relation which exists l>et \veen the
middle car and the naso-phaiynx thiough the
medium of the Eustachian tube, it is essenti.il
that a caicful examination ot the thioat and
nose should be made m all cases , indeed, this
inspection should be a loutmc pi ad ice It is
necessary both on diagnostic and theiapeutic
grounds, and the aunst should make himself
thoroughly acquainted with both the normal
and pathological appeal ances ot these parts,
and become thoioughly ethuent in the neces-
sary technique Such inspection is best made
at this stage, before inflation of the tympanum
is practised Examination of the nose by
anterior and posteiior rhmoscopy will be de-
scribed latei (we "Nose") In some cases it may
be necessary to supplement the pioteduie b) a
digital exploration ol the naso-pharynx, and in
childion this may piovo the only way ot ai liv-
ing at a satisfactory conclusion with regard to
the condition of the post-nasal space
Inspection of the fauces may leveal the
presence flf enlaigcd tonsils, when these are
found in children, especially when associated
with large pale granules on the postenoi
pharyngeal wall, the piobabihty ot the coexist-
ence of adenoid vegetations is suggested A
difficulty 01 sluggishness m the ele\ation oi the
soft palate on phonation favours the same con-
clusion being drawn It is only in veiy raie
instances that the post-nasal giowths them-
selves can 1)0 observed by simple inspection of
the phaiynx The piesence of an excess of
secretion upon the posterior pharyngeal wall
may signify the existence of naso-pharym-eal
catatrh In the examination of the antenor
nares special attention should bo paid to the
presence of spurs, ridges, 01 septal deviations 01
other obstructive agents which might interfere
with the passage of the Eustachian cathetei,
should that be found necessary at a latei stage
6. EXAMINATION m INFLATION THROUGH HIE
EUSTACIIIAN Tuiffl — The introduction of a
current of air into the middle ear through the
Eustachian tube is a most valuable and essential
aid both in the diagnosis and treatment of many
ear affections It is on account of its thera-
peutic value that due care should be taken to
accurately note the patient's power of hearing
l>efore any method of inflation l>c tried We
have already incidentally referred to it in test-
ing the mobility of the tympanic membrane,
but it finds a more extended application than
that In diagnosis, the permeability of the
Eustadnan tube, the piesence of secretion at
the Eustachian oiihco 01 in the tympanum, and
the existence of a peitoiation la the membrana
tympani may all be determined by this means
In estimating prognosis, too, it is a leliabk
guide, and as a means ot treatment it is of the
gieatest value It is necessary, theiefore, to
be thoroughly convoisant with the technique
ot the vaiiou-j procedures employed for this
purpose
Thrc« methods aie m common vse — (1) Val-
^alvaI^ method, (2) Politzer's method , (3) in-
flation thiough the Eustachian catheter
(1) ValbnlviCt Method — By tl.is means auto-
mtUtion ot the middle cat can be practised
Tho patient is directed to hold the nos»o tightly
between the finger ami thumb, to close the
mouth and fombh expne, at the same time
puthng out the cheeks It the Eustachian tubes
aio pemous, they piovide the only outlet ioi
the air which is thus foiced thiough them and
impinges upon the inner suiface of the t}mpamc
membiane As already indicated, during this
pioccduic the obser\er inspects the drumhead
thiough the autal speculum It must be borne
in mind that syncope may be thus induced in
pei sous with a wc'tik heait, owing to a too
forcible expiration with all the outlets closed
This method of inflation has a somewhat limited
application
(2) Pol it «S Ahthod —In oidei to inflate the
tympanum by this method, a Polit/er's bag and
an ausc ult.it ing tube are necessary The bag
mav\ ha\e an ait capacity of six or eight ounces,
or e\en mote, and should be piovulcd with a
vahe , its nasal end should be htted with a nose
noz7le, oi what is bettei, the extienuty should
be loxeied betoie its insertion with a small
piece of nibbei tubing This has the double
advantage of being soft, and fuithei, of securing
greatei c leanhness, .is a fresh piece may be used
toi each patient For auto-mHation it is perhaps
moie convenient to have a vulcanite nozzle
attached to the bag b} a pun e of nibbei tubmar
two 01 tin eo inches in length The examiner
should make it a routine practice to auscultate
dining inflation, as in this way he may satisfy
himself as to whether air enteis the tympanic
cavity, and as to the character ot the sound
pioduced The patient's statement as to the
hist point is not reliable Auscultation is
earned out by the aid of a long rubber tube,
each end of which is provided with a small oai-
piece, one coloured black frr insertion in the
external auditory meatus of the patient, the
other white for the surgeon's ear. It is neithei
necessary nor advisable that the patient should
hold this tube m his ear, ad\ciititious sounds
464
EAR, EXAMINATION OP
may be produced by the friction of the fingers
upon it
The operatoi stands in front of his patient,
having connected his oar to that of the patient
by means of this tube , he directs him to take
a bip of water and to keep it in his mouth until
ordered to swallow it He then grasps the an-
bag in his light hand, insciting its nozzle just
within one nostril , \\ith the finder and thumb
of the left hand both nostrils are fiimly 10111-
prcsscd The position ot the bag when held in
the light hand is oblique, lying moie or less in
the long a\w ot the external nose The patient
is no\\ directed to swallow the water — and it
may be necessaiy to say this in a loud tone, —
«ni(l simultaneously with the mo\emonts of the
larynx dining this act the bag is sharply and
forcibly squoe/ed The opeiation may be re-
peated eithei through the same nostnl 01
thiough the opposite one, the surgeon's eai
being now connected \vith the othei ear of the
patient In PohLser's method both Kustaehian
tubes are inflated simultaneously
Certain modihcations of this method hiue
been suggested, thus Holt, instead of asking
his patient to swallow watei, directed him merely
to blow out his cheeks while the mouth was
kept shut While this jnoccduie is considered
less disagieeable by many patients the entiance
ot air into the tubes is not assisted as it is
during the act of swallowing, the onhceo bemu
then opened by muscular action Holt's modi-
fication, however, has this advantage that no
ad\entitious sound is piodueed such as accom-
panies s\\ allow ing, nor is the iush of an into
the tympana quite so foi eiblc (Jriiber suggested
phonation of the word "huck" (pionounced
" hook ") Luc«e directed his patient to intonu
the vowel sound "ah "during the act of infla-
tion In both these modihcations the soft
palate is laised and the naso-pharyn\ is thus
shut oft* It may be noted here that in the rase
of young children, w hei c it is useless to attempt
to give any instructions, the act of crying is of
the greatest assistance
(3) Inflation thivuyh t/tc Eustnchum Catlutet
— For this operation the evumuei lequiies in
addition to Pohtzer's bag and the auscultating
tube, a Eustaclnan cathetci Silvei or vulcanite
instruments may bo used, the foimer possessing
this great advantage that they may be sterilised
by boiling , the gi eater pliability ot the vulcanite
instrument, however, lenders it more easy to
manipulate in the nose The catheteis vaiy in
length, in the shape of then cuive, and in the
size of their lumen, so that various anatomical
difficulties may be thus overcome In selecting
an instiument in any given case for the first
time, it is pei hap* advisable to make use of
one which has a full curve and a medium-sized
lumen. The small metal ring on the proximal
end of the catheter indicates the direction of
its point, before inserting the catheter the
surgeon should attach the Poht/er bag to the
funnel-shaped proximal end and blow air through
it, t)i us satisfying himself both as to its patency
and to the absence of any liquid in its lumen
If during the previous examination of the
nose the anatomical condition suggested a
difficulty in the introduction of the catheter,
the operation should bo commenced with the
aid of the speculum and artificial illumination ,
otherwise the patient is seated with his face
turned towaids the light
lit Staye — The suigcon, facing his patient,
fust connects his own car by means of the
auscultating tube with that of the patient
I'oht/ei's bag is placed undci the left aim, with
the large end directed forwards so that it can be
icadily giasped in the light hand \vhcnrequired
The catheter is then held lightly between the
mdev hiigei and thumb of the right hand, care
being taken not to conceal the metal ring in so
doing The iilnai edge of the left hand is laid
upon tho patient's forehead, wlul<» the tip of the
nose is gently tilted up with the thumb of the
same hand, thus remoMiigthe obstructing ledge
.it the junction of the caitilagmous and osseous
llooi The beak of the cathetei is now mseitcd
point down wauls, the Tight hand being at this
stage depressed helow the level of the patient's
thin As scxm as the point of the instrument
has slipped over the elevation of the floor just
alluded to, the light hand is at onto raised and
the cathetei brought into the hon/ontal position,
when it is pushed backwaids along the mfciior
meat us of the nose until the convexity of the
euive is felt to come in contact with the posterior
wall of the naso-phuynv It is very necessary
that the hand should be raised as directed so
that the point oi the uibtiumcnt is kept in con-
tact with the flooi of the nose, otherwise it
may pass upwards into the middle mcatus and
there prove a source of annoyance both to the
patient and surgeon
2nd titruje — When the convexity of the curve
is felt in contact with the posterior pharyngeal
wall, the point of the catheter is next totaled
tumnd* thiough a quarter of a circle, i e.
through an angle of 90, as indicated by the
metal ring , the instrument is now gently with-
drawn until the concavity of the curve is
brought into contact with the posterior free
margin of the nasal septum
•W titar/e — The stem of the cathetei is now
lightly giasped between the linger and thumb of
the lett hand just beyond the tip of the nose, so
as to prevent it slipping, its point is then
tobited (hwnwatdt and outwinl* through half a
circle and a little more, i e through rather more
than an angle of 180, and thus it slips into the
ounce ot the Eustachian tube At this stage
the metal ring is directed outwards and up-
waids towards the external canthus of the eye
of the same side. The instrument must be
maintained in this position by grasping its stem
EAR, EXAMINATION OF
105
more firmly with the left hand Pohtzer's bag
is now inserted into the funnel-shaped outer ex-
tremity of the catheter and inflation IH com-
menced This must bo done quietly and with
the least possible jerking of the insti ument, if
the bag M provided with a valve it does not
require to bo removed from the catheter after
each inflation The an may bo forced in as
often as it is considcicd necessary In older to
remove the catheter fiom the Eustachian ounce
the rotation is reversed, the point being carried
downwaids and mwaids through a right angle.
As the mbtzunicnt is withdrawn fiom tho nose,
the hand must bo earned down over the chin,
so as to keep the point free from the posterior
edge of tho palate
J)i/lcnfttef> in ttte U\e of the Cathetei — The
elevation formed by tho junction of the bony
floor of tho nose with the cartilagm ,us vestibule
may prove an imti.il difficulty, unless tho tip
of the nose is tilted up in the inannei ahcady
described Spine.s or ndges growing irom, or
deviations of the septum, may obstincl tho
entrance of the t.ithetur When disunities of
this kind exist, they may be oveicome by guid-
ing the point of the instrument with the aid ot
the mirioi and speculum, while in sonic cases it
may be necossaiy to pass the catheter along tho
nasal fossa of the opposite side (Jndei these
circumstances, stages 1 and 2 are the same as
befoic, but instead of the point of tho instru-
ment being lotated dowmvaids and outwards,
as m stage 3, it is dnectcd across the middle
plane of tho naso-pluuynx by piessing the
proximal end of tho catheter outwaid against
the ala of the nostril It is better in such cases,
ho we vei, to. mflato theeai of the same side in the
first instance, and then carry the point down-
wards and mwaids acioss the middle plane to
the c'onesponding spot opposite Difficulties
may be met with in the naso-phaiyn\ the
curve of tho cathetei may be too pxoni mined to
admit of piopei rotation, so that one with a
smaller curve must bo substituted Sometimes
the movements of the soft palate inteifetc with
the manipulation, when one 01 other of the follow-
ing methods should be adopted in place of that
already described Stage 1 is the same as befoie,
but instead of tho point of the insti ument being
rotated inwards and then withdrawn until the con-
cavity hitches against the septum .is in stage 2,
tho insti ument is withdrawn with its beak look-
ing downwards until tho concavity is anestcd
by the postei lor edge of tho hard palate , it is
then rotated upwaids and outwaids thiough a
quarter of a cuclc and a little moie On tho
other hand, some aunsts piefer at the end of
stage 1 to rotate tho instrument at once upwards
and outwards through a right angle, and then
with the point against the outer wall of tho
naso-pharynx in lloscnmuller's fossa, they with-
draw it, until it rides over tho Eustachian
cushion and slips into the orifice This pro-
VOL. 11
cedure may prove somewhat disagieoable to tho
patient.
Information derived from Inflation — If
auscultation be simultaneously prar Used much
useful information is obtained When tho an
enters tho tympanum through a patent Eus-
tachian tube, the sound produced is full and
clear, and the impact is appau-ntly close to tho
observer's own ear If tho tube is obstructed
tho sound is famtci and appeals more distant
If thoie is fluid m the tympanic cavity a faint
moist sound maybe detected, which must not
be confounded with the louder guighng noiso
produced .it tho phaiyngeal opening of the tube
In the presence oi a small dry pcrfoiation in
the tympanic mombiano the .111 m«y be heard
whistling through it, sometimes, if the perfora-
tion IH a huge one, theie is almost a painful
sensation produced m the sin geou'n ear If the
porfoiatiou is associated with secietion in the
tympanum, a moist bubbling sound is heard.
After inflation, the bearing powci must bo again
carefully tested, and the icsull tetorded
Comjjliuittoni resulting Jioni Inflation — In
some cases giddiness and s^niope have been
pnxhurd as the lesult ot inflation by Tobt/er's
method, while loss of consciousness accompanied
by convulsions is a raie accident dining cathc-
tciisation Occasionally surgual emphysema
has followed tho use of tho catheter, owing to
abrasion of the mucous membiane by the point
of the insti ument The gieatest caio should bo
practised in keeping the catheters clean so as to
in oid tho nsk of any infection The silver
instruments should bo boiled, w hile tho vulcanite
ones may be kept constantly immersed in a
solution of carbolic add without being damaged
Choice hetweeti Folit-er'i Method and the
Eustachian Catheter — In the case of children
the catheter is usually not employed An
objection may be expiessed by adults to the use
of this insti ument, nnd, to obviate the dis-
comfort which is fiequently complained of by
patients, some authonties cocainise tho infenoi
ineatus of tho nose befoio its introduction
Pohtzcr's method, 01 one of its modifications,
may in the first instance be used, unless there
is any distnu t contia-mdication The existence
of a cicatm 01 au atiophic condition of the
tympanic membrane contra-mdieates tho use of
this method, as the forcible introduction of air
may cause riiptuie of tho membrane in those
areas Moie ace mate information can be
obtained by tho use of tho cathetei with regard
to tho degiee of obstiuction m tho tubes, while
the amount of air mtioduced can also be regu-
lated In othci cases again in which there is
marked obstruction, it is tho only method by
which an can be successfully inflated and the
tube rendered more patent As both tympana
are simultaneously inflated by Politzer's method,
an unnecessary and even injurious strain may
be thrown upon the healthy ear m cases where
30
466
EAR, EXAMINATION OF
lepeatcd inflation is only requnod for one ear
Undue stretching of the structures in the
normal tympanic cavity may to some extent bo
lessened by the patient nisei tmg his finger into
the exteinal auditoiy meatus durmg the act
Bar, Local Anasthetics —-To induce local
anesthesia for operations on the eai, the two
drugs most commonly employed aie iwatne and
eucatne
The auinl operations for which local anaes-
thesia muv be icquned may bo grouped as
follows —
A On the Eittrnal Eat --Renunal of cysts
or small new giowths from the pinna 01 outer
part of the external meatus Opening of
furumles ('metting of gianulationb, etc
B On tht Middle E<ii — Paracentesis of
the membiana tvmpaui Removal of polypi
Cm citing (Ossiciilectomy, simple opening of
the nvibtoid , iadic«il mastoid opeiation )
For the lemoval of cysts, etc , from the pinna
01 outei pait of the exteinal meatus eucaiue
maybe used by injection Local awesthesia by
fiee/mg, by moans ot other 01 other spiays, ha<«
been employed, but, owmi* to the stiiutme and
blood-supply of the amide, IN not to be lecom-
mended Cocaine may be used by injection (in
solutions of 5 pei cent), but eueame is ptob-
ably the safei dnu> Moieovei, eucaine can be
stenhsod by boiling without undetgomg decom-
position, «ui .idvautai>o not possessed by cocaine
/?-eucame is soluble to the extent ot 10 per cent,
and, since its toxic effects aie practically ruf,
theie is no adxantage in using any weakci
bolution This solution should be injected by
means of a rfeuhwl hypodermic byiingc into
and beneath the skin fit the site of tumours,
etc, and ten to twenty minutes allowed to
elapse betore proceeding to operate
For the opening ot fin uncles and the curetting
of gianulations, eucaine or cocaine may be used
by instillation This method is earned out as
follows — The patient lies upon the sound side,
with the eai to be an.csthetised uppermost
The solution of cMicamo 01 cocaine, comfortably
warmed, is then chopped into the mcatus until
that passage is full, and is ic tinned for ten
minutes When the patient uses a pad of wool
should bo placed over the car to absorb the
superfluous fluid This method may be used
for the opening of furuncles, incisions into the
meatus, the curetting of granulations from
either meatus or tympanum, and for paraccntcsis
of the membrane
The above methods are, however, unsatis-
factory at the best The personal factor is so
vanable as regards the local antcsthetisation of
skin surfaces tha,f. lesults ranging from good
anaesthesia to ml will be met with The intact
memtsrana tympani, being covered with skin, in
continuity with that of the meatus, is practically
non-absorbent and, therefore, offers the greatest
obstacle to efficient local anesthesia Attempts
to obtain the latter by means of agents which
corrode the superficial epidermis have icsulted
in such mixtures as one of equal paits of cocaine
hydrochloiide, conccntiatcd carbolic acid, and
menthol This method is, however, only rela-
tively successful
Shortly aftei this ai tide was wntten foi the
first edition, CJiay ot Glasgow, taking ad van
tage of the pcnctiatmg piopeities of aniline oil,
introduced the solution known by his name
"Cray's solution" consists of cocaine hydro-
chlonde, 0 5 , aniline oil, absolute alcohol, aa
50 Hut aniline oil being poisonous, instances
ot untoward results fioin its use have not been
infrequent
A bettei niotluxl than any of the abo\e lies
in the local application of diy crystals of (ocaiuo
011 the end of a piobe
Since 1903, a modification of Schlcich's
method has been used in Polit/ei's Clime at
Vienna, and the woikcis there claim lesults so
satisfactory as to justify the abandoning of
gcncial ansDsthesia in a majoiity of ca&es This
method can be used ioi the lomoval of ossicles
and e\en foi the ladical m.istoid operation In
this counti y, howcvei, it will probably be long
befoie otologists will opeiate in this mannei by
picfeience It is stated that the h.vmonhage
attending opciations by this method is so in-
significant as to make it a distinct advantage
Schlcich's solution is a mixture of 1 per cent
wamicoiame solution with h\e drops of tonogen
(the trade name applied to Uuhtei's extiact of
supiaienal gland Tonogen coiiesjionds to the
"udionalm" of Paik, l)a\is and Co) to each
cubic ccntimetie of cocamo solution Thu
mixtine is injected undei the periosteum by
means of a special syimye A full account of
the technique to be caincd out in operating
upon the ear by this method is too long foi
insertion here, any ahiidgment would make
the dcscuption inadequate Two papeis by
Mebsib Scymoui .1 ones and Stoddart Barr will be
found in The Ttans of the Otoloqwal Society of
the United Knn/domt ^(A vi pp 127-136, in
which the mattci is dealt with clearly and
fully
External Ear, Diseases of. (Auricle and
External Auditory Meatub )
ANATOMICAL AND PHYSIOLOGICAL OBSERVA-
TIONS 467
DISEASES OF inn Aumci E 468
Traumatic A/ection* 468
Matfotmations 468
Cutaneous A/ecttons 469
Morbid Gtowths 470
DISEASES OF THE EXTERNAL MEATUS . 470
Abnormal States 0} the Cerumen 470
Foreign Jlodies . . 472
Furunculi or Circumscribed Inflamma-
tion . . 473
EAR, EXTERNAL, DISEASES OF
467
Diffused Inflammations, Eczematous,
Traunvitic, etc
Caries arul Net i ous
Stenotis (J/atfonnntion, etc)
473
477
177
ANATOMICAL AND PHYSIOLOGICAL OnsisuvATiovs
— Under the name extoinal oar aio included
the auricle and external auditoiy meatus In
form, in dimensions, and in the douiec of angle
of attachment to the head, the .unicle or pinna
picscnts gieat vaiieties in difleient poisons and
io,ces of men In stiuctuie, the iiuule consists
mainly of «i fiamewoik of yellow clastic fibro-
caitdagc, lined by peiiihondiium which is
covoied by skin The lowoi pait 01 lobule,
howovei, contains no caitila^o, and is composed
chiefly oi skin, connective tissue, and fat The
skin lining the auntie is moie loosely attached
to the eaitila^o behind than in front, \vhero
sebaceous glands .no found in gioat numbeis
Thiee muscles extend fiom the .uincle to the
side oi the head — these aic, no doubt, lumiants
of muscle* oiigmiUy intended to mo\o the
an nek1, as ,i whole, ioi \\aids, upwaids, and
bickwaids In fc\\ ptisons, hovvovoi, aie
these muscles of moie than Aciy sliuht film
tional \alue Tiaus of othei six musdes, still
less developed shuctmall> and functionally,
may ho found (ounce tniijr diHoiont putsot the
uiiiJc with one .inothei
Fttnttinn^ "f tin AID tile — The \\aves of
sound f«dlmi» on Iho contli.i ,ue icflccted foi waids,
and by the hollow foimcd by the tia<;us thev
aio fatlhei lellected into tlio moatus It lias been
found cxpei nnontalh tint the aitihual iillingup
oi these hollows IMS a ppiecubly weakened the
hearing po\\oi in peisons dull oi heaimii, who,
on the othei hand, often dcnve boneht by in-
creasing \\ith tin h.ind the leflec tinu suiface.
Eiti'nml Awhton/ Miatu\ — Extending iiom
the auTicle to the tympanic. membiane is this
somewhat winding passage, lined by a con
tinuation of the cutaneous eo\eiing of the
auncle The width oi the canal and the degree
of its cm \atme pieseut gieat ^a^etles in
<hifercnt persons Its length extends to about
in inch, lint, owmj; to the oblique position of
the tympanic membi.me at its innei end, the
.mtcro-infeiioi wall is lom»ei than the posteio-
supcrioi. The walls of the outei thud of the
nieatus aie cartilaginous, 01 lathei mein-
brauo-caitilagmous, and aie continuous with
the auncle. It is to be noted that at
birth thcie is leally no bony mcatus Tho
osseous canal develops gradually outwauls
from the squamous and mastoid poi tions of the
temporal bone above and behind , while below
and in front it develops from the aimiilus
tympamcus, forming ultimately the tympanic
plate The tympanic membrane being almost
horizontal at bnth, the space between it and the
floor of the meatus is then very narrow.
Tho lining of the meatus is skin, which
gradually becomes thinner as it extends over
the osseous portion , there it in firmly adherent
to the periosteum, which leally constitutes its
deep layer Tho lining of the cartilaginous
meatiiH, especially at its inner pai t, contains the
f/laitdula? teruinuww, winch secrete the cei iiinen
or eai wax, and are leally modified sudonpaiouu
glands
Nfiwui Dftttifaition to the External Ear —
Sensoiy nenes are derived (1) from the cei\ical
plexus, tlnough the great auncular nerve,
which t- applies the gicatei part of the auricle,
(2) from the third drvi&ion of the fifth cranial
ncne, thiough the aunculo - temporal, which
gi\cs 1 ranches to the outci s -rface of the
mini le and to the walls of the meatus , (3) from
the juirulai ganglion of the pmumogastric the
ucne of Ainold finds its way t > the skin lining
the postenoi wall of the moatus This nerve
accounts for <oitam rellev phenomena, such as
coughing, fiequently obscived when this pait of
the meatus is piessed upon with an instrument
oi foreign body The muscles of the auricle
aie mainly supplied by the facial nei\e thiough
the postenoi aunculai and tempoial >nanches
The otic i;an»hon is connectecl with the ncivcs
which supply the ^allous paits oi the extenial
and middle eai, conti oiling ami i emulating the
icilex lelations both to the \.uious parts of the
e.u and to othei legions of the body From its
connection also with the sympathetic, vaso-
motoi impulses on» mated elsewhere may be
tiansmitted thiough this jxanghon to the lining of
the « xteinal e.u as well as othei paits of the ear
Li/mi>htttn* of tin Ejteinul Eai -— Tholym-
ph.itics from the auncle and meatus pass into
the mastoid glands, the paiotid glands, 01 the
CCIMCM! under the meatus Hence the glands
in these situations aie often found tendci and
swollen m connection with inilammatory affec-
tions of the exteinal eai
Diseases of the auncle and external auditory
moatus, the paits of the oigan of hearing
haMiig a cutaneous lining, come less frequently
befoie the piactitiouei than diseases of the middle
oi mucous tract of the eai Probably 20 per
cent of the cases piesentmg themselves for treat-
ment in connection with eai hospitals or clmiques
aie affections of the auncle and external nieatus
It is to be lemembeied, howe\er, that middle
eai diseases, especially the puiulent vaiiety,
fiequcntly involve the external meatus m one
way oi .inothei This is partly due to the
anatomical lelationship of the middle ear to the
external meatus, and also to the fact that m-
flammatoiy products, formed in the middle ear,
usually escape through the mcatus, and in
doing so may infect its Iming membrane It
is, therefore, sometimes difficult to determine
in a given case whcthei we have to deal with
a primary affection of the meatus or one secondary
to middle ear disease.
468
EAR, EXTERNAL, DISEASES OF
I. DISEASES OF THE AURICLE
These -will bo described as follows —1 Trau-
matio affections; 2 Malformations, 3. Cuta-
neous affections , 4 Moi bid growths
1. Traumatic Affections — Inciwf wwinch are
common, involving, it may be, the complete
severance of the auricle. In onental countries
this is frequently inflicted upon criminals and
others. The lobule is sometimes lacciated,
either gradually by the mere weight of an eai-
rmg, or suddenly by the pulling of the eai-
ring, as IH sometimes done by a child The
cleft thus produced may remain peimanuntl}
Simple mcibed wounds should be bi ought
accurately together by sutures -with antiseptic
precautions , oven when the amiclo is almost com-
pletely cut or torn oft caieful suturing may load
to healing If the auricle be entirely lost, an
artificial one may bo substituted An old cleft
in the lobule should be tieated by carefully
paring its edges, followed by sutuimg
Traction and contusion** of the auricle may
lead to serious consequences The authoi has
seen a severe foim of mastoid penohtitis excited
in a boy thiough <i man laying hold of the
boy's ears and lifting him fiom the ground
Contusions or piolonged piossures may pioducu
rupture of the caitilage with eflusion of blood
beneath the perichondnum, forming a spelling
at the upper and antenor part of the aunclp
This is tiaumatic fuvmatoiiui awis or otluenm-
toma The skin o\er the swelling may be
unaltered, but moie frequently it has a daik
reddish-blue appeal ante, and theie is usually a
painful sensation of fulness The swelling is
sometimes duo more to peiichondiitis <aiwcd bj
the injury, and the effusion may then be seious
or soro- sanguineous, becoming in some cases
purulent Kven when the effusion consists of
blood, the colouring matter is apt to deposit
itself on the walls of the cavity, and only stiaw-
colourcd fluid may escape on punctiumg
The so-called vhtunken ear may result,
especially if the caitilage has been torn, and is
due to thickening of the tissues followed by con-
traction. It is occasionally seen in professional
boxers, and is observed on some of the classical
statues of athletes Hwmatoma auns may,
however, arise independently of injury, and the
insane seem specially liable to this (we " Hscma-
toma Auris '')
Treatment of Tmumatic I/cematonifi Auri* —
At first cold spirituous lotions, applied \vith
moderate pressure, tend to reduce the swelling
and to oppose inflammatory leaction If the
swelling continue, the application of blistering
fluid will promote absorption. The author has
found that aspiratict of the fluid, with, m some
cases, the subsequent injection of tmctino of
iodine, has been most successful Failing these
methods, especially if there be purulent forma-
tion, tho swelling should be incised, the contents
removed, and tho cavity treated by stuffing
with lodoform gauze.
2. AfalfmmatWM of the Awiclt. — Certain
malformations aie connected with family and
rtici.il peculiarities, or with habits of dress
For example, the auricle may be seen lying
unduly flat against tho head, in elderly women,
fiom the piesMirc of caps, so the prominently
jutting out eai, occasionally obsened, may be
caused, or at least aggiavatcd, by the habit of
boys pulling their caps down between the auricle
and the head Heavy ear-imgs aie some-
times responsible foi unsightly elongation of tho
lobule
The most impoi tint malfoimationof congenital
origin is that of defective development While
fntire absence oi the auricle is veiy laie, it
may be, on one 01 both sides, defective in form
and si/e, or it may be repicbentcd simply by one
01 more small v utancous or caitilagmous nodules
or ridges. These iiidimentaiy auricles may
also be faulty in position, being fiequently
faithci fonvaid and lower down than normal,
and the extemal meatus is usually either com-
pletely wanting, 01 is icpiesented by a shoit
canal, terminating in a cuf-de-sac The nial-
f oi mat ion usually mvohes some of the deep
parts, especially those external to thelabjtmth,
including the osseous meatus, the tympano-
Kuhtachian passage, and sometimes the Fallopian
canal hi the latter case theio is facial paralysis
Cases, ho\\e\ei, ha\c been repoited, though
raie, m which rudimentary aunties \veie
associated with noimal conditions of the othei
paits of the cai As might be expected, from
the nature of tho process of development, the
maxillaiy and palate bones aie sometimes found
! also malfoimcd, pioduung asymmetry of the
fate hi smh nlmoi nudities of tho auricle and
meatus there may be undoubtedly a certain
amount of heaiing, foi it is to be icmemlnned
that the lab} m i th, having quite a different
mode of development from the middle and
external eai, is not nccessai il> imolved. While
tho labyimth aiises from an imagination of the
pnmordial integument, the middle car develops*
out of the first branchial clett, fiom the postenor
edge of which the amicle is foimed
There is also the so-called fistula amis con-
tjenita — an indentation or closed canal occa-
sionally met with in front of tho tragua or on
the helix, containing whitish matenal, and it is
legarded as a remnant of the first branchial
cleft
Matjwnuitioni of excess are less important,
and generally take the form of one or two
cartilaginous or cutaneous nodules m front of a
normal auricle — the aunculai appendages of
Virchow, regarded as very ludmientary additional
.auricles. Polyotia, or complete additional
auricles, have been only very rarely met with
Treatment — For projecting ears a narrow,
elongated portion of skin may be cut out, at tho
MAR, EXTERNAL, DISEASES OF
469
junction of the auricle and the mastoid, and the
wound carefully sutured When the meatus is
rudimentary, terminating in a cul-de-sac, an ex-
ploratory mciHion may be tried, but this is
rarely attended by benefit, owing to the state of
the deeper stiuctures Foi tin aesthetic effect,
if oncauncle bo ludimcntaiy, an artificial auricle*
to match the normal one can be applied This
might, however, imolve the opeiatne removal
of the nidi montai y one
3 Cutaneous Affection*. — JEc:ema is the most
common skin affection met with on the auncle
Certain applications, such as lodotoi in or linseed
poultices, may be exciting causes, and the irntat
ing effects of n dischai^e from the middle oar
not infrequently account foi the disease In
the acute state it may at fust bo mistaken for
ciytupel.li Thru1 .ue ledncss ,nul swelling with
heat and tension , soon \osicles appeal, followed
by the exudation of a \ellowish fluid The
cpidei mis exfoliates, and/bx the diymuj of the
exudation, dusts foim o\ei the denuded cutis
In the rhioinr foi in, howe\ei, ec/ema of the
auncle is much moie common!) met with, and
it is then, in mam cases, associated with a
Minil.u condition of the face and scalp It is
frequently confined to a put of the amide
Foi example, in the foim of a led moistened
surface 01 hssuie, oo\eied with s'.iles 01 u lists,
wo often meet with it at the junction of the
auricle and the head, especially «»t the upjwi
put The foss> <>i the helix is also a i.i\ouiite
spot , and also the outei siufacc ot the lobule
and neij-hbouihood of the meatus, from the
nutation of dischaigc- from the eai Fissuios
ai»* apt to exude fluid and to bleed when touched
The skin of the amide, in whole 01 in pait, may
ultimately become considei.thly mfiltiatcd, and
yellowish blown 01 i eddish in colour, or it may
be coxi'iecl with inspiss ited seuction 01 epi
dc-imic scales In certain neglected iases the
amule ma\ ultimately bee ome a thick biowmsh-
red shapeless mass, hssuiod and co'seied with
offensne ci usts The chief subjective feature,
m tin* c hi (imc staye, is itchmoss w ith a painful
sense of heat .ind tension, when thcio is an
acute exac erbation Theie may be j«ieat in-
duration .ind thickening of the skin at the outei
part of the meatus, causing considerable loss of
hearing
Titatnwnt nf EC ema of the Amide — In the
acute stage soothing applications only should be
employed, while the amide is at the same time
piotected from piessuie The paits aftected
should bo gently but frequently sponged with a
solution of subacetato of lead, in the pioportion
op one drachm to foiu ounces of water, while
pieces of soft doth dipped in the lotion should
bo kept constantly in con tact with the morbid
surface In many cases dusting with a powdei
suits very well, such as— Ji Pulv amyli ^nj ,
zmci oxidi 5j , calammre 3n M
Ointments, such as diachylon or benzoatcd
oxide of zinc ointment, are sometimes very use-
ful, although occasionally ointments seem to do
harm The ointment should be kept constantly
applied on a piece of soft lag Hairs must bo
caiefully removed from the neighbourhood, and
the adjoining parts of the head, if these are
aftccted with oc/ema, should also be treated.
It is desnable, m severe cases, to protect the
auricle with a light and soft covering, so as to
a\ oid pressure 01 the contact of impurities In
the moic chionic forms astringent and stimulat-
ing icmedics are usually to be picierred During
an acute exacerbation, howevei, we must le
caieful to ic tui u to the soothing remedies
Mcicurml and tiny pi epai ations aie indicated
when *heie is chronic infiltration 01 great seah-
uess and di \ness, with itch m ess , but they
should not be employed when thoie aremoistme
ind ho.it The following is a meicurial prepara-
tion ui a nnldei foim — HHydraig o\id rub,
Indtaig nnnnoni.it aa j>i ^ j , adipis benzoat §j ,
ol ohvcv opt r>>] M
When a moiu stimulating remedy is demanded
the following formula may be adopted — K
Liniment calcis, ung hydi mtiatis, «ta 7)1 » liQ.
c. n boms detergent 11\>1J , ung zmci oxicl ad
5] M
When mists aie difficult to remove, it may
be necessaiy to satin ate them with weak carbolic
oil, 01 to apply a light warm poultice of bread
crumbs and then use the unldei stimulating
piepai itums, such as any one of the following —
ben/oated oxide of /me ointment , submtrate or
oleate of bismuth w ith ben/oated lard 01 A aselme ,
diachylon ointment, 01 boiacic acid and \aseliue.
The ointment should be smeaied thickly on a
naiiow stnp of soft linen which is laid into the
xanous depressions of the uuiicle , it should
iathc'1 bo wiped off than washed with watei —
the latter being done »is seldom as possible
The application of a solution of nitiate of silvei
( iO giains to the ounce of watei ) to chronic
fissuies is sometimes very useful
Internal rewtdie* aie often of sei vice In the
acute stai«e a saline npcucnt may be pi escribed
In the dnonic foims many cases aie benefited
by at seme and lion
Delicate tubciculous dnldieu should have
cod-liver oil and iron with nutiitious focxl, while
the fresh open airof the countiy is, ot course,
desnable In gouty subjects the use of Carls-
bad salts, or pieferably a visit to a spa, such as
Haiiogatc in this country, or Cailsbad abroad,
might be suggested
Other affections of the skin aie less frequently
met with on the auricle, such as hfrjmt which
lie-ie, as elsewheie, may be attended with severe
neuialgic pains Lupit* occaKionally affects the
amide both in the form of Ivpu* vulgans and
Ivjniv eiytheiiiatodes
Eiytkcma, selorrhoea, comedones, are more
frequently met with, but as there M no essential
difference between these diseases, when they
470
EAR, EXTERNAL, DISEASES OF
affect the auricle, as compared with other parts
of the body, the reader must be referred to
them for further information.
Erysipelas frequently extends from the face
or head to the auricle, and from the reddened,
swollen, and vesicated appearance, may be
mistaken for the acute stage of eczema. The
author has seen erysipelas arise from the external
meatus, and extend over the head during the
course of a purulent middle ear affection.
Abscess of the auricle is generally of a
furunoular nature, when it may be associated
with a similar condition in the external meatus.
Abscess may also arise from a traumatic cause.
Warm fomentations, antiseptic applications,
and incision are the remedies to be employed.
The reader is referred to furunculua of the
external meatus at p. 473.
Frost-bite. — When exposed to intense and
prolonged cold, dermatitis of the auricle may be
produced. The skin is red and inflamed, while
in more severe forms, occurring particularly in
persons having a feeble circulation, livid nodules,
becoming pale on pressure, appear. These may
lead to excoriation or liberation, and, in the
worst forms, to gangrene, which may result in
extensive destruction of the auricle. In the
early stage inflammation caused by frost-bite
may be treated with iced water, or gentle
friction, or the lead and opium lotion. The
frequent bathing with hot water is said to be
more efficient in some cases. The nodules are
best treated with tincture of iodine or with
collodion. Excoriation or ulceratiou should be*
treated by means of a suitable ointment, such
as iodoform, or boracic acid and vaseline. In
persons predisposed to frost-bite, the auricle
should be carefully protected from cold during
severe weather, while the general health should
be raised to as high a level as possible.
4. Morbid Growths. — Sarcoma and carcinoma
rarely involve the auricle primarily. When
originating in the auricle, cpitheliomu attacks
most frequently the upper part of tho helix,
extending to the meatus, middle ear, aud,
as a rule, to the cranial cavity. Early ex-
tirpation of tho disease by operation gives the
only chance to the patient. Benignant con-
nective-tissue formations, especially fibroma of
the lobule, are most frequent. These fibrous
growths of the lobule may originate in the
irritation caused by the wearing of ear-rings,
and they may attain to great dimensions,
especially in negro women. Removal by
operation is the only remedy. Angiomata are
occasionally met with in the auricle. Several
may exist, and they form bluish, pulsating
tumours, extending,^ it may be, to the head.
From them dangerous haemorrhage may take
place. Politzer recommends the thermopuncture
by Paquelin's thermocautere. Sebaceous cysts,
when occurring on the auricle, are treated as on
other parts of the body. Gouty deposits, in the
form of sodium biurate, are sometimes met with,
especially in the upper part of the helix or iu
the fossa of the helix.
II. DISEASES OP ran EXTERNAL AUDITORY
MBATUS
1. ABNORMAL STATES OF THE CERUMEK. —
Excess — Ceruminous Obstruction. — The cerumi-
nous secretion consists, in a normal condition,
chiefly of fatty and colouring matter forming
a circular yellowish -white layer, having the
consistence of honey, in the inner part of the
cartilaginous raeatus. When in excess it may
be semi-fluid or doiighy in consistence, but more
frequently it is dry, firm, and even stony. The
colour of tho mass varies. It is often of a
chocolate colour, while, if epidermis enters
largely into its composition, the colour is grey
or whitish. If the patient works in an atmo-
sphere containing much coal-dust or other black
particles, tho colour may be a deep black.
In addition to cerumen there enter into the
masses sebaceous matter, epidermic scales, hair,
coal-dust, etc., while, occasionally, the centre is
composed of a small ball of cotton or other
foreign body. The plug after removal may be
found covered with a dirty white membrane,
and, on its inner end, a mould of the outer
surface of the tympanic membrane is occasion-
ally seen, The ob&tructing mass not infre-
quently forms a plug filling the whole canal;
but comparatively small quantities may, on the
other hand, be sufficient, in certain circumstances,
to impede the transmission of sound.
Cause*. — These accumulations may be duo
simply to a mechanical hindrance to the natural
escape of the cerumen from the ear, sVich as — a
natural narrowness of the mentns, the presence
of bristly hairs at the orifice, eczernatous
thickening of the meatal walls, exoatosis or
hyperotitosis, or collapse iu old ago of the
cartilaginous meatus. Efforts to remove the
wax from the ear, such as by the use of the
corner of a towel or an " aurilave," may result
in the formation of a hard ball of cerumen in
the deep part of the meatus. Or the obstruc-
tion may be simply due to excessive secretion,
which in many caaes is also abnormally dry and
tenacious. This excess is often found naturally
in persons who perspire readily; but local
congestion, such as furuncular or eczematous
inflammation, may excite the glands to abnormal
action. Mechanical irritation also, such as fre-
quent scratching with the point of a pen or a
toothpick, may have a similar effect Catarrhal
processes in the middle ear are sometimes
associated with excess as well as inspissation.
In sclerosis of the middle ear, on the other hand,
the secretion is often found to bo diminished or
even abolished.
Symptoms. — Defective hearing is the chief
symptom of ceruminous obstruction. This may
come on quite suddenly, and may for a time
EAR, EXTERNAL, DISEASES OF
471
fluctuate considerably, owing to changes in
the size and position of the plug, effected by
the entrance of moisture, sudden movement of
the head, or efforts to allay itchiness. The
accumulation may go on for a considerable time
without causing deafness so long as there is an
aperture, however slight, but the entrance of
moisture during washing or in the bath may be
the immediate cause of sudden and, to the
patient, alarming deafness. Ultimately, the
deafness becomes uniformly severe owing to
complete impaction or hardening of the plug.
Subjective sounds, such as disagreeable buzz-
ing, singing or rushing, are sometimes very
annoying features of this form of deafness. They
may be reflex from pressure on the nerve twigs
in the meatus, or they may be due to direct
pressure upon the tympanic membrane, and,
through the ossicles, upon the labyrinthine
fluid.
Pain in the car is occasionally complained
of, but a sense of itcliiness or of "stopping
up" is more commonly present Pain of a
severe nature is sometimes excited by inflam-
mation of the lining of the meatus, duo to
the pressure of the hard mass.
Giddiness has been occasionally observed in
connection with impacted cerumen.
The long-continued pressure of a ceruminous
plug is capable of exciting inflammation of the
tympanic membrane ; in this way a perforation
or opacity and thickening of the membrane may
result.
Proynoxis. — Although there is manifest plug-
ging of the meatus wo must not at once promise
a cure, owing to the fact that there may coexist
an incurable deeper-seated affection. In probably
two-thirds of the cases wo shall find that either
complete recovery or improvement of the hearing
will follow the effective syringing of the ear. If
the deafness has come on suddenly, especially
after such a cause as the entrance of water,
and if there are marked fluctuations in the hear-
ing, the removal of the mass will probably result
in restoration. In many persons defective hear-
ing from ceruminous collection tends to recur at
intervals of months or years, and in such cases
it proves, not infrequently, the precursor of other
and more permanent forms of deafness.
Diagnosis. — The presence of excess of ceru-
men is easily demonstrated by the use of the
speculum and reflecting mirror, when tho ex-
ternal meatus may be found completely blocked,
or the collection may bo confined to the inner
part of tho canal, where it sometimes escapes
detection by the unpractised examiner. Masses
of epithelium, epidermis, or fungi; collections
of dried pus coloured with cerumen (concealing,
it may be, an old perforation), are apt to be
mistaken for ceruminous collection. Careful
examination may show that tho meatus is not
entirely closed by the mass, and that the deaf-
ness is really due to some other cause.
Treatment of Cervminous Obstruction,.— Syring-
ing with warm water is the only safe and effec-
tive method of treatment. The syringing may
at once be carried out if the mass be of a soft
nature, but if hard and impacted, preliminary
softening measures should be employed. The
following solution is a suitable one:— R Sodii
bicarb., acidi carbolici aa gr. vj., glycerin! 3ij,,
aquro 3ij. M. !*
After being warmed, half a teaspoonful is
poured into the ear, and allowed to remain foi
ten minutes. This should be repeated twice
during twenty -four hours before syringing.
Owing to the swelling of the mass, by the
absorption of tho fluid, the deafness may, for
the time, be aggravated, and the patient should
be forewarned of this. In cases where wo have
to .deal with masses composed chiefly of exfoli-
ated epidermis or epithelium, there may be
considerable difficulty in removing them owing
to their adhesiveness; and the cautious and
repeated use of forceps, followed by syringing,
may be necessary before dislodging and com-
pletely removing them.
A brass piston syringe, capable of containing
4 ounces, is generally the most efficient instru-
ment Tho nozzle should have a smooth ex-
tremity, and should not exceed an inch and a
half in length. The syringe should be furnished
with a fixed ledge, or other contrivance, so as to
prevent the slipping of the index and middle
fingers during its use. A black vulcanite tray,
with a concave edge to fit the irregular surface
under the ear, is suitable for receiving the fluid
as it issues from the ear ; the concave edge
should be pressed close to tho skin, wire being
taken to prevent the escaping fluid pasbiug down
between the tray and the neck. Bubbles of air,
mixed with tho water, arc very unpleasant to
the patient, and are to be avoided by expelling
the air from the syringe before beginning to
syringe the ear. The water should have a
pleasant warmth, not under 100° F. Cold
liquid must ou no account bo used. During
syringing, the point of the noxssle of the syringe
is placed just within the external orifice, in con-
tact with the roof, while the auricle is pulled
backwards and upwards with the left hand. A
fair amount of force is necessary ; but, with in-
terruptions, a stronger stream can be employed
than is safe in cases of purulent disease of tho
car. The medical attendant must not entrust
the syringe to the patient, or to an incompetent
person. In some persons, syringing the ear,
even when done with care, excites giddiness, and
occasionally considerable pain. These effects
are more likely to bo produced if the tympanic
membrane be already perforated, especially if,
at the same time, oxcessive^orce be used. When
we have reason to suspect tho existence of a
perfpration, we cannot be too careful in the use
of the syringe, which, in such a case, must always
be preceded by the antiseptic solvent already
472
EAR, EXTERNAL, DISEASES OF
mentioned It is undesnable to continue tho
syringing after the meatus is quite clear , hence
it is well to examine so as to ensure that the
opeiation shall not be continued unnecessarily
On the other hand, we must make suio that the
whole of the obstiuction hat, been removed.
After the completion oi the operation, any
fluid which may icnmm in tho eai is allowed to
dram out, and the passage is carefully dried with
absorbent cotton, it is well also that a plug of
cotton- wool be woin in the meatus for some
hours after\\aids Some injection of the vessels
of tho membiane and the inuci pait of the canal
will be observed for a shoit time after syringing
Deficiency of Cnunien — The canal of the ear
is sometimes abnoiin.illy diy and destitute of
cerumen, producing, it may be, a feeling of un-
pleasant diyncss. Tint, may coexist with defec-
tive hcairng, winch is, however, not a lesult of
the lack of cciumen, but i at her an indication
oi disease in tho middle e«u, piobably of the
sclerotic type Tieatment of the middle ear
condition sometimes leads to increase of the
ccruminous secretion The sense oi drynesb may
be alleviated by painting the walls of the meatus
with vaseline 01 othei lubiicating ointment
2 FORKION liolllbS IX THE EAR — The foiClgll
bodies most commonly found m the meatus are
beads, stones of fruit, small buttons, peas, small
stones, bits of biead, pieces of papci, fragments
of wood 01 of slate pencil They aic most fie-
quently found in tho eais ol childieu, and aic
usually intioduced by the child, 01 a companion
m play When n child is bi ought in order that
a foreign body be icmoved fiom the eai, we
must make sum that it is leally there, and must
not rest sati.siied unless w e actually see it For
it not infrequently happens that, although a
foreign body has been intioduced into the ear,
it has, unknown to the patient, found its way
out again The statement of the paliiwt must
theiefoie al\\ays be tested by the use of the
leflectnig muioi and the speculum This is in
most cases ^ely eat>il) done by any one having
moderate expei lenee, in inspecting tho eai Thei e
may, ho \\c\ei, 111 some cases, be difficulties in
the way of actually seeing the foieign l>ody. It
may (1) ha\e passed or been forced into the
tympanic cavity, Ihiough a pcrfoiation in the
membrane , (2) if a small object, it may be con-
cealed in the depression at the inner end of the
floor of the canal, especially if this be unusually
deep, (.3) it may be \ciy difficult to sec owing
to the swollen condition of the walls of the
uiuatus , (4) it may be embedded in cerumen ,
(5) a shaip object may ha\c penetiatcd the s»km
of tho meatus in these A arious conditions, the
careful examination by an expeiieneed observer,
with the help of a pr^bc or syimgu, will usually
oveicome the difficulty
With regai d to the symptoms produced by a
foreign body in the eai, wo must emphasise tho
fact that small, smooth, round bodies may re-
main for many years m the meatus without
piovoking irritation — if undisturbed If there
be but slight pressure on the walls of the meatus,
the symptoms may be limited to a degree of
dulness of hearing with sounding in the ear
On tho other hand, if the object be larger, and
especially if it has been foiced deeply into the
meatus, violent pain maybe excited, both from the
picssure and fiom the inflammation which ensues
Rare cases are recorded of persistent cough, con-
stant sneezing, giddiness, and vomiting, and
even epileptifuim attacks, due to foreign bodies
in the eai, the symptoms disappearing aftei
their removal There is no doubt, howevei,
that the most serious consequences of foreign
ladies in the car have been duo to the injudi-
cious 01 unskilful use of instruments foi their
icmo\al Tho author has known death itself
icsult fiom such efibits, and lie has also known
grave injuries inflicted on the structures of the
ear from the use of instruments intended to
lemove a foreign body, \\hich \\as, howevei,
pioved to have no existence there
Removal of Foteit/n Jtodie* fiom tJie Eat — If
the foreign body bo snmllei tlhin the lumen of
the canal, which it usually is, and if it has not
been dm tin in beyond the naiiow pait oi the
meatus (the isthmus), the use of a syimge and
warm water will, in the mnjmdy of t«*e«, ensure
the expulsion of the body 1 f w e find on examina-
tion a free space between the walls of the meatus
and the foreign bodj, the stieam of waini water
should be dnccted into it A syringe such as
that used for the icnun.il of impacted cei union
M suitable, and the auncle should be pulled well
upuaids and backwards with the left hand,
while the child's head is inclined somewhat
dow n\\ aids tow aids the atiVcled side, in older
to assist the movement oi the object out \\ aids
When tho foieign body has leached the outer
orihce, it can be. easily i omened \\ith a small
scoop It is to be noted that, if the foreign
bod) be a pea or other vegetable substance, it
may, fiom absorption of the fluid, become more
niinly impacted after syrim-ing We should
theiefoie be piepared to use other means im-
mediately aftei the farluie of sji urging
When, however, the foieign body is found to
be impacted deeply in the c anal, especially if it
has been foiced, either at its mtiodiiction m m
the subsequent efforts to remove it, beyond the
narrower portion of the canal, into the space
wheio the flooi dips down and the canal widens,
its removal m.iy be a matter of great difficulty
If, through inflammatory swelling of the walls
of the meatus, the foreign body has become im-
movably fixed, tho difficulty may, for the time
being, appear insuperable In such tightly
impacted foreign bodies we should first examine
carefully foi any space, howevei small, between
the foreign body and the walla of the meatus,
HO that a stream of watci fiom a syimge may
be directed into the space and behind the foreign
EAR, EXTERNAL, DISEASES OF
473
body, with the hope that the latter may be urged,
by the pressure of the fluid, towards the external
ounce If, after a fair trial, syringing should
fail to expel the object, some form of instrument
must be resorted to No one, however, should
attempt extraction with an instrument in such
circumstances, especially in the case of a child,
without the use of chloiofoim or other general
anaesthetic.
The patient being under the anaesthetic, the
interior of the ear is thoroughly illuminated,
through a speculum, by means of a leflectmg
mnroi on the forehead A thin but stiong in-
strument, slightly curved, such as one ot the
blades of Dr Guy's forceps (nimiatmc midwifeiy
forceps), is introduced between the foreign body
and the wall of the meatus, selecting a gap, it
such exists, and used as a lovci to mge the body
outwaids Such an instrument should be as
line and small as possible, compatible with suffi-
cient stiength, bccausn it is often a matter of
much difficulty in such cases to pass ex on a thin
mstiunicnt between the walls ot the meatus and
the foieign b<xly, while the foice \\hidi may be
necessary in older to pnsc the object outwards
can only be safely employed with a strong in-
strument If practicable, the msti ument should
be introduced antero-mfeiioil}, wheie the tym-
p inic mcmbiane is farthest away fiom the orifice
of the cai Lister's hook is suitable when the
foieign body is not too deeply situated A con-
tinent mstiuineut is to be had haMng Guy's
cm\ed airangemcnt at one end and Listei's
hook at the othui Ordinal} forceps should, as
u iiile, be discaided, as the} tend to impel the
object faither m, only when the foreign body
IN close to* the oiihee of the eai, 01 xeiy small
m si/c, aio the} permissible, and then s} ringing
is preferable If we aie able to encnclu the
object with a stiong wne loop, used with Wilde's
biiaie, it may be possible to bi nig it safely aw a} ,
or so change its position tlial syringing may be
biiccessful, 01 the use ot the le\ci mstiuinent
rcndoiod possible In the case of a vegetable
substance, su<h as a pea, tightly impacted, a
fine bent hook may be used to bleak it down,
aftei wards the fragments are expelled with a
b} i mge Low cnbci g suggested that a fine brush,
dipped in a solution of glue, should be applied
to the foreign body, w ith the hone th.it adhesion
may take place and allow of the foieign body
being bafcly withdrawn In the case of long-
pointed objects, lying aeioss the meatus, it may
be neccssaiy to break them with forceps and
extiact the pieces sepaiatcly or syringe them
out If the torcign body has passed through
the tympanic mombiane into the tympanic
cavity, its lemoval with the wne loop should be
attempted The author has not found any help
in such cases from the air douche, 01 fluid injec-
tions through the Eustachian tube, or buction
with Siegle's speculum, as suggested by some
authorities
If these various methods piove unsuccessful —
the foreign body being immovably wedged in
the inner end of the meatus or in the tympanum
— we should make a long incision at the junc-
tion of the auricle with the mastoid process,
dissect the auiicle and cartilaginous meatus for-
wards, and thus gam ac cess to the osseous part
of the meatus, nearer to the foreign body A
strong lever instrument can then be more safely
and effectively employed The wound should
be carefully sutured, and the meatus plugged
with lodoform gauze foi a few days In the
event of failure, as a List resort the postcuoi
wall ot the osseous meatus should be removed
with the bur 01 chisel, and, if necessary, the
antiuin mastoideum can be opened
Insects, su( h as ileas, earwigs, bugs, etc , may
hud their way into the ear and excite alarm m
the mind of the patient Then presence may
not onl} pioduce the sensation of a moving body
in the ear, but, by fastening upon the skin of
the meatus 01 the tympanic membrane, seveie
pain may be excited There is no c\idence that
the eaiwig is an especially dangeious inmate of
the eai, as popularly believed Maggots may
be found in the ear, especially if the lattei be
the seat of a puiulent discharge, from the de-
position ot the eggs of the fly, probably attracted
by the purulent odoui Insects are easily ex-
pelled fiom the I'Jii by syringing with watei, or
o\en by pouimg water or oil into the ear, allow-
ing it to remain toi a icw minutes The smoke of
tobacco, blown into the meatus, usually leads to
the departure of the insect In the case of
maggots rectified spnit may be ponied into the
eai, and after a tune the use of the syringe will
generally expel them It may be necessary,
how ex or, to pick them out with forceps If a
leech should find its way into the car, syimtrmg
with a solution ot common salt will ensure its
expulsion
3 FlJKUNCUll OR ClRf ITMsriUBKD IXFLAMMA-
IION oi -HIE KXIFRNAI MEAiub — Synoii}ms
Otitis cxtcina ciuumsciipta , boils in the ear
This is one of the commonest mflammatoiy
aflectioiib ot the exteinal ineatiiH, and is often
associated with l>oiis else \\heie The inflam-
mation has its oiigin in u ban follicle or gland
in the subcutaneous tissue, generally m the
cai tilaginous part ot the meatus A core of
sloughed tissue usually lesults with more or less
puiulent formation, the lattei may be xery
slight, or it may constitute a distinct abscess
We geneially find more than one in the same
ear, and they ha\e a maikcd tendency to
recur
CaiiMS — While 110 doubt essentially microbic
in origin, local n ritatmg conditions arc important
factors in the causation of tUese fuiuncuh. The
special microbe, which enters the hair follicle
and excites the inflammatory process, is the
btaphylococcus pyogencs, aurcus or albus The
disease is often associated with scaly eczema of
474
EAR, EXTERNAL, DISEASES OF
the meatus, when the mechanical efforts to re-
lievo the fooling of itchinesa scorn to induce it
Furuncuh are also a not uncommon complication
of purulent middle ear disease, probably owing
to infection dei ived fiom tho piuulent discharge.
The constant presence of muihtuio in tho meatus,
the temporary entrance of cold watei while bath-
ing, or tho use of iiuUnts by way of ticatment
may excite the disease Like most diseases, it is
often attributed by patients to cold No doubt
certain defective states of tho health may pie-
disposo to these1 fuiuiicuh, such as diabetes
(See" Boils")
Symjftonn — Pain in the eai is the chief symp-
tom This w sometimes intensely acute, mdiat-
mg, it may be, o\ei tho side of the head, while
frequently thei o is a painful pulsation in the cai
described as a " hammer ng ", these p.unful
sensations aie always woiso at night Mo\e-
monts of the amide tend to aggiatatc the pain ,
so does piessuie, such us lying upon the auricle,
01 pressuie on the tiagus The pain is also in-
tensified by ino\ements of the lower jaw, as in
chewing, yawning, and even speaking When
the boil is on the postenor wall of tho meatus
there may be pain on picssure oxer tho mastoul,
which may sometimes be cedematous , while, if
ovei the antenor wall, the fiont of tho tragus
may be swollen and ^ cry tcndei to touch The
hearing is usually ioi the time defect i\e, owing
to the paitial 01 complete occlusion of the meatus
by the swelling, while theie is often a humming
01 buz/ing sensation in the eai In seven 6 cases
febrile distui banco may be piesent When ex-
amining the ear we should at hist simply leflet t
light into the meatus without a hpec iiliun, as the
use of tho latter may bo \eiy painful If then1
be any secietion m the canal the lattet should
bo gently syunged and caiefully (hied \\ith
cotton-wool We may then find two 01 e\en
three fuiuiicuh m diftoient stages, and tho meatus
entirely closed bj the s\\ elling The skin over
the furunculus IH usually reddish, and when
pics&cd with A piobe is oxtiemelj sensitive
6'otirv — The mrtamnuitoiy eentie may de-
velop into a distinct abs( ev>, but moie frequently,
after a few days, the boil ruptuies, giving exit to
a small slough and a few drops of pus, with relief
to tho pain Tho pus 01 slouch may lequuc to
be piessed out of tho little out ice with a probe
Granulation tissue occasionally spiouts fiom tho
opening, but the disease Aeiy larely leads to
any affection of the bone Excessive foimation
of cpidoiruis or ceiumen sometimes follows an
attack
DKHJMVIS — Tho natuie of tho affection is
dctci mined by the soft localised SA\ellmg, veiy
sensitive to piessuro with a pi oho, and also
by the pain elicited dining piessuie upon or
traction of tho auricle It may in a slight ca&e
look like a small pimple at the onfice of the
ear. Wo must not confound the axlema over
tho mastoid with actual peuostitis
Treatment. — Antiseptic and sedative plugs
intioduced and kept m the ear aie \ery useful,
such as an ointment composed of 1 gram of
menthol, 2 grams of lodofoim or boracic acid,
and 1 drachm of vaseline , this is smeared
thickly on long cotton-wool plugs, introduced
well into tho meatus and changed every few
hours Caibolic acid and vaseline, 1 in HO, may
bo used in the same manner An ointment
composed of 1 giam of hydrochloiate of moi-
phine to 1 diachm of vaseline has a sedative
effect These plugs should not be allowed to
pi ess painfully on the walls of the meatus, but
made simply to occupy the canal so as to bung
tho antiseptics m contact with the inflamed
aioas Some piefer the use of antiseptic solu-
tions, especially m the lecurient foim of the
disease, such .is boiacic acid and alcohol 1 in 20,
01 perchloiidc of men my 1 in 2000, but the
author has found tho antiseptic plugs piefciable
Wai inth and motstuie, in the foim ol linseed-
meal poultices 01 hot fomentations, fiequently
applied o\ei the eai, into which an antiseptic
plug has been placed, aie distmetl> useful in
relict mg the pain These applications should,
howcxci, bo discontinued as soon as the pain
is relieved, as theie is no doubt that excessive
poulticing tends Aciy much to the leimiencc
of fuiuiicuh Asa mlc it is well to avoid the
enhance of liquids, such as oils, into the eai,
and wo should .11111 lathei at keeping the eai
pcifectly diy, with the exception ot the anti-
septic plugs If springing be necessai}, the
eai should be aftei wards most caiefully mopped
out with absoibent cotton-wool Aftoi syinm-
mg and di}ing, the insufflation of a small
quantity of fine boiacic powdei, Jbefoic the
intiofluctioii of the plug, is uselul wheie the
canal is not completely closed It tho fuiunculi
affect an eai alieacly the seat of puiulent middle
ear disease, it is doubly impoitant to employ
diy treatment In such a case the ear as a
lulo rcqnnes to be syimged with antiseptic
solutions, butgie.it caie should be taken to diy
the whole of tho meatus by means ol absorbent
cotton, on a cotton-holdei A little diy boiacic
powder is then blown m and the antiseptic
cotton-wool plugwoin
If tho pain, in spite of such remedies, con-
tinues so as to pi event .sleep and cause much
sufluimg, an incision is made into the seat of
the inflammation A slendei and shaip-pomtod
blade, such as a fine tenotomy knife, is suitable,
and wo should cut fiom below upwards, this
being less painful Tho contents of the boil
arc then pressed out with a piohe, and tho fore-
going treatment carried out If an amesthetic
bo not admmisteied, the head should bo held
firmly, as tho inflamed tissue is very sensitive
to incision, which, however, is generally soon
afterwards followed by marked lehef Granu-
lation tissue, if present, should be removed with
forceps followed by the use of bone powder
EAR, EXTERNAL, DISEASES OF
473
If there be chiouic scaly eczema of the meatus,
appropriate treatment must bo employed, so as
to prevent iccurience of the boils
In peisistently iccurrent furuncnili, geneial
treatment may be very uHeful We should
regulate the diet, the use of stimulants, exer-
cise, etc The possibility of the patient Buffer-
ing fiom diabetes should be kept in view II
there be an.emia on the one hand, or plethora
on the othei, v\c must pi escribe appropnate
treatment Ai sonic may be employed in the
poisistent foims, \vlnle sulphide of calcium is
a remedy \voithy of trial
4 DiPJUMii! INFIAMMAJION OK THE EXTMINAL
MBAIUS — Otiti\ Ettctna Dtffum — Tina includes
a variety of conditions in \\hicli the cutaneous
lining ot the moatus, of ton including that of the
tympanic membiane, is involved in the mfidin
matory piocess In the sevoie foims the peri-
osteum of the bony meatus usually paitinpatos
The following vaiioties may be distinguished
(a) The tt < mutual foim, which inanifosts
itself in the acuto stigo by icdnoss and swelling,
with copious soious exudation and opidermic
formation It is frequently based upon cb ionic
scaly eczema ot tho meatus, 01 it m.iy be an
extension fiom oc/oma oi tho auricle Jodoform,
used in the tieatment of middle oar disoaso, is
sometimes lospunsible for it rinouic eczema
may bring about stenosis of the nioatus fiom
giadual thickening ot its lining membiane
(A) TtttuHMtic Ottln jEjtniw — This foim
may bo due to (1) tho nisei tion of foioign
bodies in the e,n, 01, moio commonly, nnpiopoi
attempts to it move them , (2) the mtioduc-
tion oi iriitating oi caustic substances, sucl1
as scalding watei, cold watei, cfiemical and
caustic substances, (i) the unskilful use of
installments , (4) injuries, Mich .is punctuiod
wounds, fiactuio thinugh the toof ot tho moatus,
fiactuio ot the tympanic plate Tho lattoi may
bo caused by a fall ti om a height in w Inch great
force is applied to the chin , the blooding horn
tho car which takes place in this ni)iny may
be readily mistaken foi iiactuie of the base
of the skull
(c) tiyp/ufttie OtitH Eiterna — This is a lare
.affection, and may occui eithoi in the pimiaiy
or in the secondaiy stage of the disease It is
usually seen in the form of condylomata and
ulceiations, which are apt to leave cicatrices
or pigmental y patches , the formei sometimes
seriously contacting the canal They usually
occupy the outer onfico of the ear, appealing as
a greyish-ied mass of granulation tissue, yield-
ing a foetid discharge The liberations have
a dirty- white appearance, cncular in shape.
(d) PamvtH Otitii J£*«mw— -This form
(otomycosis) is due to the growth and accumu-
lation of fungi, gencially belonging to the genus
aspergillus, found chiefly on the inner third
of the canal, and tho outer surface of the
membrane Damp dwellings generally favour
their formation Tho fungi seem to develop
most frequently in a meatus where there has
been an accumulation of epidermis or common,
foimmg a nidus for tho germination and giowth
of the paiasite The two chief forms of fungi
found in the car are, 1st, ttqxiyil/ui rm/riw/is,
foimmg a blackish collection, 2nd, ayenjillw
flavfttnt, in n huh the spoies^form yellowish
points — the collections being whitish or greyish
These fungi adheic very tenaciously to tho
osseous walls of tho canal and to the tympanic
membiano , and, \ihen icmoved, the cutis be-
neath is m1, piobcnting scauetimes a bleeding
tendency
It tlio fungi be not iradicited there is a great
tendency to u lapse oi the inflamrnation Mith
much pain No doubt those collections of fungi
aie soinotiinos togaidod as simple cciuminous
in epidciiuu accuinulations Ir those sho\\ a
tendency re.ulil) to iccin, and especially if theie
be (onsidoiablo pain, muioscopic examin.ition
should IK* made
(?) CioujMiumtH? Dtjihthfi itic liifldnitnation —
This foim is i.uo, and is geiioially .issociatod
\\ith phiuiixgcal diphthoi 1.1, although it has
liecn kiurou to OLCIU in the nioatus indepen-
dently of tho thi oat In thus vanety theie is
a duty gie^ish mcmbi me, \\hich adheres to tho
osseous inuatns, and on tho separation of the
mcinbi.ino ti bleeding sinfaee is cxpohtd
(/ ) tfftumlttiy Oti ht EitntM — In acute
otitis media tho lining of the osseous meatus
is almost always imohod, but the chrome
middle eai puiulont aftiu tions htill more fie-
qucntl} m\ol\e tho mo.itus Tho mastoid
antiuiu .uul mastoid (ells aic closely lelatod to
the postoio-supeiioi \\.ill of the bony meatns,
so th.it punileut collections not infrequently
make then \\.iy tluouuh the la) or of bone scpai
atmu, these sp.icis and buno\\ undoine.ith the
lining ol the nuMtus, in, l)iusting thiough the
linmtij.i hstulous < onnmnnuition v\ ith tho meatus
is toimod The gioator pait of tho postoio-
supoiioi bdii) v\all ma) thus bo dostioyod, vuth
01 without tiio fonn.ition oi soquostia Even
tho vihok1 of the boii} tissue mtei \omng be-
tween the me.it us and the antouor knee of the
lateial sinus may in some tascs bo dostiojed
These conditions hhow thomschcs by profiihe
dischaigc and by cxubeiant gianulatuui tissue
01 polvpi which spimg up and fic(iuoutly fill
tho nioatus
Symptoms nf thtv' Ktnou* twin1* of Otitit> E*~
teuia — In tho acuto stage the subjective symp-
toms (onsist of pain, impairment of hoaiing and
subjo(tnc sounds 3 they can scaicely be distin-
guished fiom those attending the uicumsciibed
\aiioty ot inflammation Like the latter the
pain is usually agui av ated 4>y movements of the
jaw, 01 by prossuic 01 fraction upon the auricle ,
and the heaimg is impancd in propoition to the
degree of sv\ oiling, and the amount of inflam-
matory products, as well as to the degree in
476
EAR, EXTERNAL, DISEASES OF
which the tympanum participates In severe
forms, at a very early stage, the epidermis may
be elevated by effused blood, causing one or
more bluish swellings in the bony meatus, which
may lead to considerable discharge of blood
from the ear (otitis cxtcrna hfKmorrhagica).
After a short period of hypersumia and swelling,
with, it may be, hremorihagic clcnations, a dis-
charge from tho meatus appears In the cexe-
matous vancty there are usually itchmess, heat,
and sense of fulness, and, on examination, we
find in tho moatus serous or purulent seoiction,
with, in many cases, laminated masses of sodden
epidermis After removing irflainm itoiy pro-
ducts by cautious by ringing and cliying, tho
meatal and tympanic sin faces aie usually seen
to be red, swollen, spongy, 01 gianular from
loss of epideiniis In the eh ionic stage, giauu-
lations are apt to spimg up, while the dischaige
acquires a disagreeable odoiu Glandular en-
laigoments of the neck or swelling over the
parotid gland an* likewise not uncommon If
treatment be neglected or insufficient, especially
if the patient lia/o an unhealthy constitution,
the disease 14 apt to go on indefinitely, and may
bring about such consequences as the follow-
ing — (1) stenosis of the meatiw, fiom hvpei-
tiophy of the cutaneous limns, 01 from hjpei-
ostosis of the bony walls , (2) canes or neciosis
of tho osseous pait (this in, however, a much
more frequent lontilt of middle eai disease) ,
(3) perfoititiou of the tympanic memhi.tno and
extension to the middle eai, or opacity and
thickening of the tympanic membrane, (4)
owing to the defective state of the tympanic
plate in the younur child and to the i lefts in the
cartilaginous meatus, inflammation of the ex-
ternal meatus is apt, at that time of life, to
extend to tho articulation of the jaw and tho
parotid gland, (">) fatal implication of tho
incnmges, brain, or lateral sinus may icsult
by extension through the loof 01 back wall
This, howevei, is \ory laio compaied with fatal
extension fiom tho middle ear spaces
As milammatoiy affection^ of the meatus aie
veiy ottcn associated with middle ear discise,
it IH sometimes difhcult, m a given case, to
decide which is tho pumary condition, while,
owing to stenosis of the meatus, it may bo im-
possible to determine accuiately the state of
tho tympanic membrane 01 middle eai From
fuiuncular inflammation the diffused foim is
distinguished by the localised nature of the
former as tested by a piobe. If the inflamma-
tion bo ec/ematous, we shall find othei symp-
toms of ec/eina, such as itchmess, scalmess, and
occasional seious discharge In the parasitic
form, microscopic examination is necessary in
Older to foim a coirett diagnosis This variety
is to be (inspected, if a condition lesembling a
cerummoiib collection is attended by severe
pain, difhculty m clearing out tho moatus, and
tendency to iccur
Treatment of the various farm* ofOMi* External,
0i/u8a.—In the acute stages, abstraction of
blood, by moans of leeches, will have a mitigat-
ing influence, especially in removing pain. Two
leeches applied over the tragus, and two at the
lowei part of tho mastoid, will afford sufficient
depletion in tho case of an adult. After the
bleeding has ceased, the good effects are en-
hanced by the use of hot fomentations. In
milder cases, or when there is not much pain,
icmoval of blood is unnecessary Gentle syring-
ing with hot water, in which 2 per cent of
boiacic acid has been dissolved, is also calculated
to soothe pain Warm poultices of linseed meal
applied over tho ear are also soothing, but they
should only be used while the pain is at its height,
and should be discontinued as soon as there is
lehef A few diops of tinctuie of opium 01 of
the following— R Liniment belladon , liniment,
opu aa 7>n M — placed on a plug of cotton-
wool, and inserted in tho outer orifice, usually
aflbid lehef to pain Tho gelatine preparations
of tit nl mi (amygdalie annum) aie preferred by
some These contain, foi an adult, either Jth
of a giain of liquid extract of opium, or ,\th
of a giain of hydrochlorato of moiphme They
aie introduced with aural foiocns, and the
moatus is afterwards closed with cotton-wool
The gelatine gradually dissolves, and relief to
the pain follows If the pain should be intense,
pi eventing sleep, an internal sodatnc, such as
Do vet's powder, or the subcutaneous injection
of morphia, may be leqimed at night In the
acute condition rest and quiet in the house,
espocially during wmtor weather, contribute to
the iccoveiy At tho same time a plug of
cotton-wool should be kept in tho oifhce of the
eai, while a pad of cotton- wool is placed over
the side of the head
When tho secreting stage bogms and in-
flammatory piod nets occupy tho moatus, tho
ear should bo gently syringed onco or twice a
day, or less fiequently if the secretion is slight,
with a hot solution of boracic acid, then dried
as fai as the tympanic membrane writh absorbent
cotton on a cotton holder, and H small quantity
of finely powdered boracic add blown in As
noon, however, as the secretion has ceased to
form, tho parts should simply bo kept dry.
Granulation tissue must, if present, be removed
with a snare or suitable forceps, followed cither
by the boracic treatment, just doncnbed, or by
tho spirit tieatment. The latter form of treat-
ment is applied as follows — After syringing
with a solution of boracic acid and drying out
the oar, a solution, consisting of equal parts of
rectified spirit and water, well warmed, should
bo poured into tho ear and allowed to remain
there for ten minutes— repeating the process
twice a day till tho ear be perfectly dry When
tho condition of the meatus depends upon a
purulent affection of the middle ear, these
zcmcdics arc specially suitable
EAR, EXTERNAL, DISEASES OF
477
In the eczematous form of inflammation,
when the walls of the canal are thickened, and
iu the diy scaly condition, elongated plugs of
cotton smeaied with an ointment such as
the following — Hydrarg. oxid. rub, hydrarg.
ammomat. ai gr vj , adipis benzoat. §j , ol
olivco opt. r>U M —should be uiHerted twice a
day, so as not only to stimulate absorption, but
also to exercise a certain degree of piessure
In the more peisistcnt forma of thickening, a
strong solution of nitrate of {silver (40 grams to
the ounce of water) should be painted <x\er the
walls of the nioatus t \\ice a week, for seveial
weeks After each application a ball of cotton,
soaked in a solution of common stilt, is applied
for a few seconds to the onhce of the eai to
prevent blackening of the skin In the thy
scaly foim, without stenosis but with tiouble-
somc itching, we should use, m addition to the
foregoing tieatment, the following — 1}« Audi
carbohcigi v, spirit ratif ."jij , glyceinu'ij M
Sig — Koi punting external meatus twice daily
If the niilainmation bo of a specific, nature,
general anti - syphilitic treatment should be
employed The < ondylomata may be cut off
with seissoisi, and chromic acid then applied
Occasional dusting with calomel powdei will
also piove useful An ointment, containing 10
gnuns of lodofoiui to an ounce of \uselme, may
sometimes bo applied % ith advantage
In the tieatment of the paiasitic form, the
effective, use of the syringe, with «i 2 per cent
solution of boiacic or carbolic acid, as ahead)
mentioned, may ha\c to be lepoated seveial
times be f 01 e the masses tan be lemoved, and
the aid of foiceps may be necessaiy Some
decided parasiticide, such as lectified spmt or an
.alcoholic solution of bichloride of mercury (1 giain
to the ounce of lectified spnit), t\\icc a day foi
a week, may be icquuud to prevent rccurience
Such solutions, aftei being pouicd into the cai,
should be allowed to remain there foi fne minutes
While local treatment is of fust importance
in these inflammations of the external meatus,
geneial lieatmcnt, especially m the chiomc
forms, contributes to recoveiy, such as the use
of non, cod-livei oil, nutiitious food, abundance
of fresh open air, etc ; anti-syphilitic remedies
m specific cases, arsomc m cczcnmtous cases ,
alkalies and apciicnts in gouty conditions
5. CARIES AND NECROSIS OP THK EXTERNAL
MBATUS — While caries and necrosis may occui
primarily from inflammation of the osseous pait
of the meatus, it is important to remember that
bony affections of the meatus aie usually put
of a purulent middle car disease, especially
affecting the posterior wall through the prox-
imity of the mastoid antrum and cells In such
cases the upper and back \vall may be first seen
to bulge, owing to pus forming under the skin
and periosteum The bone forming the outer
wall of the attic of the tympanum is not in
frequently involved, leading to exposure of the
head and neck of the malleus In canes and
necrosis there is a purulent, often samous,
discharge from the 3ar, and exuberant granula-
tions spring fiom the seat of the diseased bone,
which bleed readily when touched These may
ill the canal of the ear, and they recui aftci
removal There are often othei manifest evi-
lences of mastoid and tympanic disease A
>iobe may show baie turn bone, especially on
,ho back vail , at other times theie is a mo\able
sequestrum 01 the probe may pass through a
canons apeiture into the cells behind.
Treatment of CVi??es and Iffcrwti — A soft
lging in the uppei and back pait of the canal
may f,iat lequne to be incised, when canes or
neuosw of the bone beneath maj be found In
the cuse of a linkable t>equcstnun, syringing
iiuij be suthuuit to remove it , failing that, a
pan of stionn foiceps must be c nplo^ed, while
the patient is undoi ( hloioioim A long-pointed
sequestium, fixed tians\erscl} in the meatiib,
may loqnnc to be bioken before lemoval.
Sctiucstia of consideiable si/i, usually coming
f lorn the mastoid wall, aic often rc-mo\ed fiom
the meatus One 01 nioic neciotic ossicles may
also escape, 01 be icmou'd fiom the meatus
Caie must be taken, aftei the ienuv\al of a
sequestinm, to pie\eut stenosis, by plugging
with nairow stups oi lodofoini gauze In many
cases canes oi nenobis of the posteio-supenor
wall of the meat us can only be dealt with
elhciently by opeiating through the luabtoid
It may then be found that the postcro-supeiioi
wall of the meatus has been alieady destroyed
by canes 01 necrosis, 01 the opaatrve tieatment
may necessitate the removal of that pait of the
meatus YV heie the middle eat spaces aio really
the sources of the mischief, the thoiouph tieat-
ment ot the puiulent middle ear disease must
be icboitfd to This will be found desciibcd in
the «u title on puiulent disease oi the middle
ear A supcihual canons spot can be safely
and successfully t met ted b} a small shaip spoon,
and the opeiatioii should bo followed by the
application of lodofonu and boiacic acid, one of
the fonner to three of the latter Any consti-
tutional defect or cachcxia must bo tieated by
appi opi late i emcdies
6 STFXOMS 01 HIE ArpA'ius — («) Menosikfioni
Malfoi nation — The orifice of the cni may bo
icdticed to a mere slit, fiom the appiovimation
of the anterior to the postciioi wall, due to an
iivei -flaccid state of the nbious tissue and skin
in old persons If this interferes with heanng,
a small siher tube, ha\mg the shape of an
ear speculum, may bo kept in the eai during
the waking houis Congenital malformation is,
however, nioie important, when it is usually
found in connection with a gpngcmtal defect of
the auricle, the meatus being at the same time
absent 01 icpresentcd by on indentation, or a
small canal teimmatmg m a cul-de-sac. There
aie also usually m such cases congenital defects
478
EAK, EXTERNAL, DISEASES OF
m the middle ear, and, therefore, opeiative
efforts to foim a propel canal very laiely icsult
in benefit to the healing In a very few cases,
where the congenital conti action has been
limited to the outer end of the meatus, benefit
has followed the cautious use of sponge tents
A partial closure of the meatus is sometimes
caused by a marked projection of the anteio-
mfenor \\all of the osseous poition — this only
proves inconvenient by impeding the examina-
tion of the lower pait of the membrane
(b) Stenosis ftom Swelling or Thidcniny of
the Cutaneous Lining — Tho most common cause
of this form of stenosis is chiouic ec/cmatous
inflammation The persistent nutation of the
mcatal lining, caused by a puiiilcnt discharge
from the middle oar, maj also m tune load to
swelling .uid thickening, causmu pai tial utcnosis
Undci this heading may also be included partial
or complete stenosis duo to abscess, tumoui, or
enlargement ot tho paiotid gland in fiont 1'us
may, in the foimoi case, hud its \\ay fiom the
paiutid into the meatus Fuiuuuiili may also
completely clo,o the meatus Knelling arising
from mastoid disease frequently also obstnut
the meatus lioin behind
In the tieatment of the^e foims of stiictuie
of tho meatus, wo should hist deal a\\ay, by
syringing \\ith a \\.\\\\\ solution of boiacic acid,
any matcn.ila, such .is putulciit, coiummous, 01
epidermic collections, which aic apt to collect
m a 11,11 row channel If theio be e^ematous
thickening and no middle eai disease, we should
treat this as already described In many cases,
however, \\G ha\e to deal with a dischaige fiom
the middle oai Then caieful tle.iusing and
diymg of the nauo\v passage, alonij with gentle
eftoits to dilate it, should be camcd out Tho
more legular iiitioduction of a cotton -wool
cylindoi, foi tho puiposo of diyiiii> tho passage,
has a somo\\hat widening effect, and still mote
so if the elongated plug be smeared with some
stimulating ointment, such as lodofoiui or
boiacic acid and v.iselmo, and retained con-
stantly m tho oai, changing it mght and moin-
ing Such plugs should bo giadually mcieased in
thickness, as the increasing lumen of the canal
permits Patients, when taught to introduce
those simple plugs, can often effect maiked im-
provement, even when the thickening is partly
bony in character With increased width of
the meatus, treatment of tho middle eai can be
more efficiently carried out In the more in-
tractable forms, sponge or lammaria tents, pro
forably the former, may be tued, but with
caution A severe and rapid dilatation must be
avoided, and the tent should not bo allowed to
remain in the cai more than an hour at a time,
nor repeated more frequently than every third
or fourth day, while tho surgeon should be at
hand to remove tho tent if much pain is excited.
A small comcally shaped vulcanite orrubbertube,
placed and retained in the canal after tho dilating
efforts have ceased, may be useful m maintaining
the dilatation, while it facilitates syringing as well
as the escape of secietiou from the middle ear
(c) Stenosis from the Formation of Septa or
Adhesions — A mcinbianous septum sometimes
foims across the meatus, leading to its entire
occlusion It may be mistaken by the mex-
penenced observei for the tympanic membrane ,
but its nearness to the outei orifice and tho
absence of the usual features of the tympanic
membrane distinguish the one fiom tho other
Tho septum moie frequently takes tho form of
a membiano \\ith a hole 111 the centre. A
ccitaiu extent of tho meatus may be closed by
adhesions, duo to the long -continued contact
of ulceiatcd suifaces, or to the coalescence of
granulation tissue The detective hearing in
such cases vill depend on the extent of the
closuio and on the condition of the middle ear
\\hoio we tuid septa 01 adhesions, the middle
ear is 01 lias been the seat of puiulcnt disease
A mcinbianous septum, closing the canal,
should be lemovod by a cnculai incision, and
an antiseptic cotton-wool plug 01 .1 strip of
lodofoim gauze mtiodueod, so as to ensure an
open space, until tho healing process has been
completed Adhesions hate to be tieatod by
scpaiation with a fine bl.ided knitf, followed by
plugs, as in the i.ise of septa
(V) tS'tfiiosfs from //wc/r>sfows of the Jfeatu*
— Hypeiostosis is hunieiitly due to ehiomc
ptuulent middle e.ir disease, guing rise to
chronic peiiostitis oi the me.it us with mcieased
formation of bone The < utaneous lining is also
usually loddish and somewhat thickened The
lumen of the canal may be leduced so as scarcely
to admit ot an oidmaiy probo, and, when due
to puuilont middle eai disease, usually contains
secretion It is to be lememlieied th.it if tho
closure of the meatus be \eiy gieat m these
purulent conditions of the middle ear, dangerous
leteiition of pus m the deep paits may result
llyperostosis is occasionally found in j ounection
with non-purulent middle eai catarih From
exostosis, hypcrostosis is distinguished bj the
diffused uniform thickening of the latter.
The tieatment of this form of stenosis is in-
cluded in that of tho second \anety
(?) Ntenosw 1ioin Exottoses or Otseout Turnouts
— Tlieio aio two varieties of cxostoscs of the
meatus — (1) those with broad bases, usually
multiple, very hard, even ivory in texture, and
terminating in apices, which approach each
other so as to leavo a small spaco between ; (2)
those having a narrow pedunculated attachment,
usually spnngmg from the posterior meatal wall,
and occurring singly
Cause — Aural exostosis seems frequently to
bo associated with hereditary predisposition or
constitutional peculiarity, and the ivory or mul-
tiple varieties are probably m many cases con-
nected with the gouty or rheumatic diathesis.
They are certainly found more commonly in
EAR, EXTERNAL, DISEASES OF
479
men of middle age who eat and dunk gener-
ously The ivory varieties are not only usually
multiple in the one ear, but they aie as a rule
found m Vith eaib The softer or pedunculated
vanety has, no doubt, m most cases, its origin
in imtation or inflammation of the posterior
wall of the meatus, bccondary, in most cases, to
an inflammatory process m the mastoid cells,
\\hich has led to peiio&tcal thickening or a small
abscess It is supposed that jiianul ition tissue
first forms, which giadually undergoes a pioce^
of ossification
It seems piob«ible that the frequent entraneo
of cold vvatei into the eai tends to lead to these
giowths, and we often find on mquny that
patients with aural exostosos have been much
111 the habit of diving m watci duimg the esuliei
puiiods of then lives It has been found bj
ttlaku ,uid othei s that the ciama of the aboiigmal
inhabitants of America, who lived on mei l)anks,
show the pioHciite of evostoses in the curs teiu.uk-
ably frequently, the explanation being that they
spent imicli of then time m the watei Ain.il
evostost"5 die also *• ud to bo coimron amount
the South Sea Islar-lois, wlio aie notable diver*
in the- sea
Nymjitom* nn<] (W/sf— -Auial cxostoses ,ue
frequently found in peisons who aie not coii-
suous of anything beuio VMOIUJ with tho eai
The patient may come to the smgeon owing to
deafness duo to some othei cau^c, when the
piesence of thoso giowths is incidentally found
by the smgeon In these cases the singeon
may see se\ei,il knob-like pi ejections of uoiy
baldness, pale m coloiu, veiy sensitive to the
touch of a piobo, and existing in both oais
Thoio is usually .i space between then apices,
through which a poition of the tympanic mom
buino may lie seen This space may, howe>ei,
at some time 01 othei become closed by c«pi
dcrmu. 01 lurummous collections, causing deaf-
ness, which In ings the- patient foi advice The
pedunculated \aiiety, spunking fiom the bony
back \\all neai Us junction with the caitilagmous,
is mote likely to go oil to complete ilosuie of
the moatus, the skin covering it becoming
slightly red and thickened When complete
closuie takes place pain may be excited, and
there is serious nnpaiimunt of heat mg It is
self-evident that, when the meatus is quite
blocked by tho giowth, the occurrence of a
purulent disease in themiddlo ear might load to
gravo consequences
The piesenco of cxostoses is usually cosily
determined by the cautious use of the piobe,
with good reflected light, when they aie distin-
guished by their hardness, comparative paleness,
and circumscribed form An oxostosis may in
some cases be confounded with a furunculus in
the ear, but only by inexperienced observers.
Treatment ofAwal Exostotis, — In many cases,
where the growths do not close the meatus, no
treatment need be adopted The contracted
lumen is, however, apt from time to time to be
completely closed l»y epidermic 01 ceruminous
collection, producing deafness These should be
removed as desciibcd at p 471 Tho softening
and removal of the masses situated beyond the
cxostosis may be facilitated by sjiingmtr through
a fine clastic tube introduced tlubugli the n.u
io\v space In this WAV operative treatment
maybe indefinitely postponed If a purulent
condition exists, eithei m the middle car 01 in
tho meatus itself, appiopiiaU* treatment should
bi employed \Vlwn tho iwatus beromes en-
tirely blocked 1>3 the IH.IIV giowths, operative
treatment is iu-<ehsar\, not only to iclieve the
deafness and subjective sounds which exist, but
also to ,i\eit the risk of puinlent formation and
lotcn ion in l lie doepei paits
Mtthixh nr OjHKttuiy — A gcncm! anesthetic
i- ucM(.bSti\ It the * cvostosis ha& a slender
peditle ,\- niav be able to lemove it by en-
luclmg the- giowtli, if that l>e possible, witb a
Jaivih nasal snaie The .uithoi succeeded with
a galvanu snaiem a <ase whole the jM^bcle was
of tnnsiupialilo tlnckiifss In these peduncu
lated c,iscs hue but stiong dentist's foiceps may
be used with sue* ess, 01 ,i tij) or two of a mallet
upon a Mutable chisel may be sufficient to bring
the glow th away
Many opeiatois now employ a drill 01 bui
piopellod by n dental entriue 01 an clcctro-
motoi A vanety of buis and (hills should be
at hand , i speculum may be uiniecessaiy if the
c\ostoses aie jnotty accessible, but good light
leflected into the eai is essential The ti.igus
is piessed well loiwaid, .uul li possible a fine
steel guaid is mticxlm-erl behind the growth
Owing to the bleeding, ficquunt mopping with
absoibcnt « ottou-v\(M>l is ie<|imed, and the opeia-
tion may thus oiuipy.i consuleiablc time It
wo have to deal with the multiple, haid vaiiety,
the apices should be mound away by a small
bin till a sufficiently laige opening is made
When the giowth is Lugp, lound, and of a
softei textuie. its base hhould first be peiforatcd
with a small drill Till tlie healing piouess m
complete, naiiow stiips of icKloioim gaiue should
be pietty liimly packed into the meatus so as
to keep the canal open In many eases, how-
ever, it is safei to expose the bony growth, by
hist making an incision behind the auncle, to
the extent of an inch and a half down to tho
bone, and then displace the auncle and carti-
laginous meatus so as to fi ecly expose the bony
giowth In this way the bur can be employed
moie safely than m operation through tho
meatus Some prefei, after exposing the cxos-
tosis, to use a chisel and mallet behind the base
of the growth The auncle is replaced, and the
wound carefully sutured, ^vhile the meatus is
treated by strips of gauze, as already mentioned
The author has found this a very safe and satis-
factory operation
7 EPITIIELIOMA OF THE EXTERNAL MEATUS —
480
EAR, EXTERNAL, DISEASES OF
When occurring m tins part of the body epi-
thelioma usually first shows itself by a simple-
looking abrasion, going on to thickening of
the floor of the cartilaginous meatus This is
followed by ulceration, with surrounding swell-
ing and induration, involving after a time the
tragus, the mastoid tissues, and the auricle.
There is a constant fc«tid discharge, while un-
healthy-looking granulations sprout up Pain
of an intense and persistent nature is a most
prominent symptom, frequently pi eventing any
sleep Suspicion is aroused as to the* true
natmo of tho disease by the fact that the usual
remedies have no effect on the pain, dischaige,
or swelling As time goes on the n hole organ
of hearing becomes involved, including the
Fallopian canal, while the cranial cavity is
ultimately invaded, and the bones m the neigh-
bourhood of the ear may be extensively exposed
Thcio is facial paialysis, followed eventually by
menmgeal or ceiebral symptoms Heath usually
results after from one to two years
Treatment — If tho case be seen m the veiy
early stage, thoicvigh excision of all MHible dis-
ease should be attempted , but, unfortunately,
before coming under obsei vation, it has usually
extended HO fai that operative treatment is
scarcely admissible Then leijular antiseptic
cleansing, with soothing iemedies,is all that can
be done
Ear : Affections of Tympanic Membrane
ACUTE INI-LAMMATIOV 480
CHROMC INHAMMATION . 480
ClIAMiES HFfcULTlN'U MIOM PRfcMOUS Is-
*LAMMATION 481
NEOPLASMS 481
INJUIULS 481
MEDICO-LF<J \i, \spsns 482
ACUTE INFLAMMATION - Acute inflammation of
the tympanic membiaue, or myimgitis acuta,
is by no means t ommon as a primary condition
In some cases ot otitis externa, and in almost all
examples of otitis media, the diumhcad partici-
pates to some extent, but such aie described
under " External and Middle Ear " Apart from
this, howevei, it sometimes happens that the
membiane becomes inflamed owing to injury
caused by the inseitiou of nibtiuments, or by
irritants such as cold 01 chemicals Violent
syringing is also sometimes icsponsible foi acute
myrmgitis
The most prominent symptom is seveie pain,
and this may be associated with tinnitus of a
hammeiing character Deafness, as we shall
presently see, is not voiy maiked when tho
inflammation is confined to the drum membrane,
on tho other hand, acccitam amount of constitu-
tional distuibanco and fever may exist On
examining the ear the membrane is seen to be
congested m the early stages, the parts chiefly
affected being tho immediate neighbourhood of
the malleus and the periphery, while the deeper
portion of tho meatus may also be involved. At
a later stage the whole surface becomes uniformly
reddened, and the outline of tho malleus is no
longer to be distinguished Sometimes serous
and haemoiihagic blisters, and even small ab-
scesses, appear on tho surface, but more fre-
quently, after the stage of umfoim redness, the
surface epithelium becomes sodden and thrown
oft m white flakes Eventually the affection
may lead to perfoiation
The diagnosis depends upon tho symptoms
and the objective changes The only cases
which ought to be diagnosed as acute mjrmgitis
are those in which the above-desciibcd changes
in the membiane exist, associated only \\ith
slight deafness. There is a method by which
diagnosis can bo assuiod, but which should not
bo employed dm mg tho acute stage, as it is then
hui tf ul I icfei to passing the Eustachian
catheter while the ear of the suigeon is con-
nected \vith that of the patient by means of nn
auscultating tube In a ease of simple myrin-
gitis no moist sounds will be heaul on the pass-
age of air, while in acute middle ear inflamma-
tion these can bo detec ted As this proceeding
uici eases tho pain, and as it is, moreover, of no
impoitanco fioru a therapeutic point of Mew to
difteicntiate inflammation of the drumhead alone
from tho same condition associated with acute
otitis media, this methcxl should not be practised
The prognosis is as a rule favourable, even if
perfoiation has occurred Tho treatment must
be regulated to a great extent by the severity of
the symptoms In any case, it will be desirable
to keep the patient in the house, or, if necessaiy,
confine him to bed Cold applications to the
ear may bo tried, and, if well tolerated, con-
tinued, while leeching o\ei the mastoid region
undoubtedly gives relief As a rule, howexei,
tho pain will be readily allayed by the instilla-
tion of a few diops of the following solution —
Cocam hydrochlor
Acid caibolic
Glycerine
aagi v
or a solution of menthol in parolemo up to 20
per cent may be used in the same manner. If
these remedies fail to grvo relief, incision of the
inflamed part may be dcsnablo Of course, if
there bo evidence of retained serum, blood, 01
pus, this indication becomes emphasised. So
long as tho inflammation lasts the meatus should
bo plugged with sterilised dressing
CHRONIC INFLAMMATION OF THE TYMPANIC
MEMBRANE — Various changes m tho tympanic
membrane, which may be traced to inflamma-
tion, are by no means uncommon Thus in
chronic middle ear suppuration a number of
different appearances may be met with. Again,
in catarrhal and fibroid conditions affecting the
tympanum the membrane is frequently impli-
cated. All these are, however, better discussed
EAK: AFFECTIONS OF TYMPANIC MEMBRANE
481
in connection with middle ear disease. Pro-
longed irritation of the external surface may
lead to congestion, followed by appearances of
dermatitis. Various changes have been de-
scribed, eg (I) throwing off of epidermis, (2)
the formation of granulations, (3) ulceiation,
and (4) perforation, the last-mentioned three
conditions being associated with moro or less
suppuration
According to my own experience the only form
of chronic mynngitis worthy of practical con-
sidoiation ID that in which the external surface
of the drumhead is soon to bo thickened, so that
the landni.irku <tie mote ot loss obhtriated
Even then, howmcr, the malleus can usually be
traced, although its outline h«is lost definition
Sometimes, in addition, scales of epidermis are
thrown oft, and the apjxMiance is that of a
chronic scaly eczema The ticatmcnt must
depend upon the result of objective examination
If gi animations b« present, they should be
cautoiiHcd \uth 11 it 1,1 to of sihei or chromic acid
fused on a probe The present e of pus indicates
e.uefiil syringing with bone lotion, followed by
diymg out and the insufflation of powdered
boric acid or instillations of re< titled spirit In
the chronic scaly foiui, which will bo often
found associated with cc/cin,i of the moatus, the
application of nitrate of silver dissolved in
spirits of nitrous ether (10-20 gi ad 33.) \vill bo
found cffecti\e, while the eai must be kept free
fiom epithelial accumulations by means of the
syringe If siuh aocumulations ha\e already
occmred, they may be soitened by means of a
solution of bicaihonatc of soda (15grs)man
ounce of equal paits of w.iter and glycenne
CliANGE» IN THE TYMPANIC MEMBRANE WHICH
IOLLOW PREVIOUS INFLAM MAI IONS — These con-
ditions will be fully descnbed m another part of
this work (p 483) I shall, theieforo, merely
lofci to the fact that a eicatnx always indicates
that thero has at one tune been a peifoiatiou,
due possibly to myrniiptis, but piobably to
middle car suppuiation Ag<iin, the piescnce of
calcareous deposits, although not pathognomomc,
is strongly suggestive of previous acute or cb ionic
suppuration Atrophic patches, on the other
hand, indicate chiomc middle tai catairb
NEW GROWN™ AND Cum IMC INFECTIVE
(iitANULOMATA — In certain cases aural polypi
seem to be attached to tho margins of a
perforation, but I suspect that this is a very
rare occuirenee, as these gio\vths commonly
have their oiigms \uthm the tympanum
Horny growths, < holesteatomata, vascular
tumours, osseous deposits, cysts, gummata, and
tubercle ha\ e been described The last named
is usually associated \\ith a tubeiculous con-
dition of tho middle c.ir In such c<ises the
membrane may sho\v yellow nodules which
break down and lead to destiuction of tissue,
thus increasing the si/c of tho already existing
perforation
VOL II
INJURIES OF TUB TIMPANIC MKMKRANK. — The
drum membrane may be injured by direct
violence. Thus some persons are fond of boring
in their ears v-ith instruments of various kinds,
and a sudden accident may drivo the extremity
against or through the membrane Such lesions
are most commonly found * i tho anterior seg-
ment A not unconunor fotm of lesion is found
in cases in which alxirtive attempts have been
made with instruments to lemove real or imagined
foreign bodies by unskilled prisons, while rarely
one meets until ca-»es in \ilnch boiling liquids,
ha\ ing b»»en poured into the ears, have produced
bums, followed by poifoiation Sudden changes
oi nil pressuie cithct on the inner 01 outer side
may lead to peifoiatiou of tho membrane.
Thus in i bulky and cicatrised diumheads the
use ot 1'ohtzer's bag may be followed by
perfoi.'uon, and the same rnay result from
Loughiiig, sneezing, or blowing the nose Again,
boxing tho cais, sudden loud sounds, diving,
etc , may lead to the same lesult
Fractures involving the ouseous meatus, and
hequently the base of the skull as well, may
lead to injury of the tympanic membrane In
some cases ot dno(t \iolencc not only is the
cliumhcad perfoi.itcd, but the handle of the
malleus may be fiactmud The symptoms vaiy
considerably accoidmg to the cause, and moie
paiticulaily aceoidmg to the amount of violence
used
In most instances of the occuirenee of a perfora-
tion, or even of an mjmy shoit of perforation, a
sensation of sound is experienced at the moment,
associated, of course, with a good deal of pain
This pain may pass off ijuu kly, but, on the other
hand, if infection of the tympanum has occmred,
it continues, and the case nms the course usual
m acute otitis media Theie may also bo a
good deal of bleeding, and the heaimuj powei is
al\va}s impaired, but to a \ aiding extent A
ceitam amount of \eitigo is bj no means un-
common
On examining the eai aftoi mjuiy to the
membrane, the appearances, of course, vary
within veiy wide limits If only a superficial
lesion has resulted, \\e usually mid a localised
area of inflammation, frequently associated with
the piesenco of coat- ula oi ecr hymoses If such
coagula bo \v itched from d ly to day it will
be seen that they me giadually moved towards
the penphcry of the membiane, and then on to
the wall of tho rneatus, a phenomenon probably
duo to ex cent nc gro \vtli of the epithelium.
When an actual peiforation has taken place, the
shape and size of the orifice will vary according
to tho instrument with which the lesion has
been inflicted m cases of direct violence If the
orifice be small it may be* covcicd by clotted
blood, while if it bo large extravasations and
coagula will be detected in the surrounding
parts On tho whole, it will probably bo best,
in cases where doubt exists as to the presence oi
31
482
EAR. AFFECTIONS OF TYMPANIC MEMBRANE
absence of a perforation, not to allow diagnostic
zeal free play Obviously an invisible orifice
may be rendered visible by removing blood
which covers it, but m doing so the burgeon
may infect the middle ear, and produce acute
inflammation of the tympanum Again, by Val-
salva's method, or by employing the Eustachian
catheter, the piesence of a porfoiation can be
detected, but under most circumstances it is
safer m those cases to trust to sight
The most common forms of perforation, such
as are produced by blows, loud sounds, explosions,
etc, aro usually seen as somewhat lo/eiige-
shaped openings This conformation is pro-
duced by the fact that the breach is usually in
the cncuUr fibics of the membianc and parallel
to the radiating fibres Sometimes instead of
being elongated the opening becomes circulai
In either case the pale yellow mucosa of the
tympanum may l>e seen through the porfoiation
As a result of severe explosions veiy extensive
injuries aie sometimes seen Thus I can recall
an instance in \\hich both membranes presented
irregulat runts, so that actual flaps were turned
or folded over
The piognosis depends mainly upon two
questions, viz (1) whether secondaiy infection
of the tympanum has been avoided, (2) the
amount of deafness which exists
If, unfortunately, an acute middle eai inflam-
mation has icsulted, the piospccts of the patient
must be judged by the rules applicable to this
disease If the hearing power be only slightly
impaired, \\e may feel fairly confident that it
\vill soon become completely restored On the
other hand, should marked deafness be present,
and moie particulaily if bone conduction be
impaired, the piognosis should be guarded, at
least until obvious improvement has begun to
manifest itself In uncomplicated cases the
perforation gradually heals, the time occupied
vaiymg according to size and shape Whcie
perforation of the membrane is associated with
fracture of the base, the importance of the
latter, of couise, completely overshadows the ear
lesion Treatment m traumatic perforation of
the membrane is chiefly negative It is of the
utmost importance after the injury to avoid
syringing, instillations, and the like The ear
should as soon as possible be plugged with
sterilised wool or gauze The patient must
keep quiet for a day or two, and avoid alcohol
and tobacco Should pam occur a cold compress
may be applied o\er the oar Should inflamma-
tion of the middle ear set in, the treatment recom-
mended in another section must bo carried out
MEDICO-LEGAL ASPECTS — In examining a case
of traumatic perforation from a medico-legal
point of view, several points have to be con-
sidered Thus, if the injured membrane be
cicatrised, and more particularly if there be
calcareous deposits, it may safely be assumed
that a relatively small amount of violence may
have sufficed to cause a rupture. Again, if an
injury has been followed by middle car suppura-
tion, the surgeon will no longer be able to
differentiate this from a case due to other causes
The history, when accurately obtainable, will
be of assistance, but it is well also to examine
the uninjured ear. If there be evidence of past
or present suppuration, this will weigh in favoui
of the affection on the other side not being
traumatic. Another important feature is the
amount of deafness and the presence or absence
of bone-conduction If the hearing be much
impaired, and it bone-conduction be lost, the
injury must be considered as serious. It is then,
of course, incumbent upon the medical man to
exclude malmgeimg, which may be prompted
by a desire for heavy damages It is also well
always to make a careful objective and sub-
jective examination
Ear : Acute Inflammation of the Middle Ear
DEFINITION 182
iMWODUCrOHY 482
CLASSIl'lCA'llON 483
CAUSES 48.*
PATHOLOGY 48o
SYMPTOMS 48")
RESULTS 486
DIAGNOSIS 48(>
PROGNOSIS 487
TREATMENT 487
DEFIMHON — Acute inflammation of the middle
ear (otitis media acuta) is a more or less scioiu
inflammatory process affecting the whole 01 some
portion of the mucous membrane lining the
middle ear, tending oithei to resolution 01 to
the f 01 matron of pus, and sometimes losulting
in serious complications and the extension of the
inflammation to important ncrghbouiing parts
INTRODUCTORY — Without entering fully into
the anatomy of this region it \vill be axhisablc
to define veiy briefly what is meant by the
" middle ear," and to diaw attention to one 01
two anatomical points which have an important
bearing upon some of the complications which
may result from a middle ear attack
The term " middle ear " comprises not only
the tympanic cavity, but also the mastoid
antrum, the mastoid cells, and the Eustachian
canal These parts arc in comnmmcation with
one another, and with the naso-pharynx, by
means of the Eustachiau tube, and aie separated
from the external auditory meatus by the
tympanic membrane The tympanum, 01
"drum of the ear," is a nairow, n regular space
in the substance of the temporal Ixmo, and is
placed between the external meatus and the
labyrinth. Extending across it is a bridge of
small bones, articulated together, which serve
to bring the membrane, the outer boundary of
the cavity, into communication with the sound-
perceiving apparatus These bones are known
EAR- ACUTE INFLAMMATION OF THE MIDDLE EAR
483
as the ossicles — the malleus, the incus, and the
stapes. The head of the malleus, and the body
and short process of the incus, are situated
higher than the upper margin of the membrane,
and occupy what is called the upper tympanic
cavity or attic Along with their attach incuts
and some folds of mucous membrane they help
to subdivide this cavity into a iminbei of pockets,
the lowest of which is known as Piussak's space,
which has as its outer boundary the mcmbrana
flaccida, or Shrapnell's incmbi ano Inflammation
and suppuration affecting this region is apt to
be \ery intractable and troublesome to treat
On the inner wall of the tympanum will be
found the fenestia ovalis 01 opening into the
vestibule, and the fenestra rotunda or opening
into the cochlea, both of \vhich aie closed by
membianes The loof of the tympanum, 01
logmen tympani, is a thin layer of bone forming
In ti.of the middle cranial fossa, which is m
'appeal^ with the dm a mator on its upper suifacc
Kn „ ^opposite to the middle and an tenor pait
oi the tympanic membiane is n smooth, rounded
pi ejection known as the piomontory In front
of this we meet \\ith tin* enhance to the osseous
pprt of the Eust.u hian tube, while behind and
tit^/c the fenestia o\,ilis is pait of the bony
anal which contains the fau.il neixe
An opening in the uppei p«nt of the postenoi
\\all of the tympanum c oiuninincates with the
mastoid rintrum, a ca\ily oi \arymg size Its
roof is ( ontinuous w ith that of the tympanum,
and is sepaiated fioin the dm a mater by the
same plate of bone, which is sometimes -veiy
thin The flooi of the .intinni is nt a lowei
le\el than its opening oi i oiiiiuunicatioii \uth
the tympAium, and hence secretion docs not
dram with ease fioin it Lowei down and moie
superficially aie a numbei oi sin ill pneuin itic
spaces kno\Mi as the mastoid cells, and occupy-
ing the mastoid piocess The) Aaiy much in
size in different mdmduals and at different
periods of life
The lelations of the middle eai to neighbour-
ing structuics, such as the biam, the sigmoid
sinus, the facial neive, and the innei eai, lequne
vciy caicful consideration when \ve icmcmbei
the possibility of the extension of inflammation to
them, but they will lequire moic detailed notice
when the complications of chiomc suppmatrvo
inflammation and then opeiative tieatiuent are
under consideration
The somow hat complex cavities forming the
middle cai are lined thioughout with mucous
membrane, which is continuous through the
Eustachian canal with that of the noso-pharynx
The diseases of the middle ear will be seen to be
due to varying degrees of catairh or inflammation
of this mucous lining, and the disturbances of
the function of the organ of hearing associated
with them are generally caused by the patho-
logical changes which lesult from these
processes.
Middle ear inflammation is of impoitance, not
only on account of its great frequency, but also be-
cause it is liable to aftbct permanently the function
of the organ to a \ cry senous extent, or to produce
complications of an exceedingly grave character
According to Gruber, symptoms of otitis media
were present in about two-thirds of all ear cases
seen in his out-patient clinic While acute
affections probably account for only a small
proportion of these, it is evident that the bulk
of them must have commenced, at some period
or othoi, with more or less acute symptoms
CLASSIFICATION — Vanous attempts have been
made to classify acute inflammations of the
middle ear on a clinical or pathological basis,
but without any very piaoticol result. It is
\eiy usual to divide them into acute catarrh
.uid acute suppurativc inflammation, and it has
also I -eeu proposed to scpaiate them into a mild
type and a scveie type These divisions do
not seem to cover quite the same giound, for an
acute catairh, as often seen in childien, may be
very severe, while a siippuratno attack may be
of quite a mild type Although the onset of a
scions 01 purulent dischaige does establish a
fact which gives a distinct indication for treat-
ment, yet the classification into perforativo and
non-perforative cases docs not find favoui, for it
gives no leal mfoimation as to the course 01
seventy of the individual ease
We pioposo, therefore, on clinical grounds, to
subdi\ ide acute otitis media under the following
headings —
1 Acute catanh of the middle ear without
cHusion
2 A( ute inflammation of the middle eai with
mueo-serous effusion In this a pciforation may
in may not occur
3 Acute puiulent inflammation of the middle
eai In this a peiforation always occurs
As will be seen latei on, these die ically
difteient stages of the same disease, and any
individual case may stop shoit at the earlier
stages, or may pjiss thiough them with such
lapidity th.it it is only the lattei stage that is
lecognised
It is not uncommon to find that authors
devote a sepaiate chaptei to the consideration
of inflammation of the membrane (inyrmgitis)
Pi unary mynngitis may be pioduced by direct
exposure 01 injury of the membrane, oi may
follow ec/ema of the incatus, extension of in-
flammation in the external auditory canal, or
may lesult fiom foieign bodies 01 plugs of
wax piessiug on the membrane, but it is
doubtful if the inflammation so set up can be
limited for any length of time to the membiane
Wo shall therefore consider acute inflammation
of the membrane as in lecJhty an inflammation
of the cavity of the tympanum, possibly differing
somewhat in extent and degree.
CAUSES — Acute middle ear catarrh is common
in damp, cold climates It is frequently met
484
EAR ACUTE INFLAMMATION OF THE MIDDLE EAR
with ID early life and in those \vhoso occupation
necessitates exposme. Heredity, the gouty,
rheumatic, tuberculous, and strumous diatheses,
and previous attacks, seem to be predisposing
causes. It may result ftom local conditions
affecting the eat primarily, but in far the laigei
number of cases it spioads by contiguity fioni
local or general conditions affecting the nose
and naso-phaijnx
Among tho conditions affecting the car
directly we may mention injury to the mem-
brane from a blow on tho cat, 01 fiom mibkilhil
efforts with installments to leimrvc plug's of >va\
and foreign bodies, or fiom the attempt to
relie\e irritation in the meatus ty means of
pins, etc , or from the instillation of very hot
lotions, caustics, and coriosivu dings suggested
by kind but injudicious friends The mischief
may be started by a cold \vind blowing on the
car during a railway jouincy 01 \\hile driving,
or by water getting into the meat us during
washing or sea-bathing Reflex irritation due
to the eruption of teeth in child i en, 01 when
the teeth aie diseased, has sometimes a huge
share in producing and keeping up attacks of
middle car catarrh Among the loss frequent
causes of otitis may be mentioned fractuic
through the temporal bone, mtra-tympanic
haemorrhage in Blight's disease, and m}cosis
and fuiunculosis of the external mcatus (vnle p
473) By fai the larger number of cases, how-
ever, are due to morbid conditions of the nose
and uaso-phaiynx Any of the various tondi
tions which tend to cause and keep up a catarrh
of the iia&o-pharyiiK, such us an ordinary coiyza,
hypertroplned tonsils, adenoid \egetatious, in-
fluenza, diphtheria, mumps, and many others,
frequently prove to be tho exciting cause oi an
otitis media The rhinitis associated with the
exanthemata often tends to affect the middle
car, and scarlet fe\ei and measles aie special ly
prone to produce acute purulent otitis Nevt
to these two diseases adenoid vegetations pioh-
ably account for the largest number of the less
severe attacks
When patients «ue desciibed as being specially
liable to attacks of middle ear catarih, it does not
follow that theie is some hercditaiy 01 inherent
condition m the car to account foi this tendency,
but it will almost invariably bo found, on in-
vestigation, that some nun bid state of the nasal
or pharyngeal mucous mombianu exists, the
removal of \vhich \\ill go fai to pi event the
recurrence of the attacks
Various micro-organ isms ha\e been discovered
in the discharge coining from the ear, and thcie
can be little doubt that they have an impoitant
influence in causing and maintaining the dis-
eased condition The organisms chiefly met
with, according to tho observations of Lowcn-
berg, Zaufal, Moos, and Nettei, are the follow-
ing — (1) the streptococcus pjogenes , (2) the
staphylococcus pyogenes , (3) the pnoumococcus
of Frarrkel , (4) the pneumo-bacillus of Fried-
lander, and (5) the tubercle bacillus. Orne
Green records the results of a bacteriological
examination made of the first diop of pus
obtained after paracentesis in 101 cases of
acute suppuration of the tympanum Pure
cultures weie obtained in 73, showing staphylo-
coccus in 36, streptococcus in 10, pneumococcus
in 10, bacillus diphthciuc in 2, and bacillus
pyocyaucus m 3 cases There \\ere also 28
cases of mixed infections
Investigations made by Leutert tend to show
that cases of otitis media \v ith the pncumococcus
aio generally milder than those associated with
the stioptouxcus In the ioimci the duration
of suppuiation was shorter, the febrile reaction
less marked, and the injury to bone, it piescnt,
\\as less pionounced All the same, he found
subdural abscess more frequently \\ith the
pneunioeoecus than until the stieptoc<
Ho attempts to explain this by supposip Bar
the smallei dcstiuction ot bone caused by o>_
foiinei rondeih extoinal cliamage moie difhcult
The attacks of otitis \vith the stieptxx occus are
apt to be inoi e \iiulciit, ^\ith gi eater damage
to bone When sinus thrombosis occurs it is
almost always associated \\ith this organism
Acconlmg to Green, A\ho has talmlated
cultuies made fiom 144 cases of diseased mas-
toids, \\e maj find any of the common varieties
of miciobo in mastoiditis, but the staphjlococcus
is irioie fiequcnt thtin the sti eptococcus He
does not believe that the special oiganism is ot
much importance in this disease, and thinks
tli.it vastly moie depends on the histologieal
and anatomical peculiarities of the bone than
on the variety of the murobc >Uufal has
shown that the normal tympanum m labbits
i ontains genus, and that organisms aie abundant
in the naso-pharynx It is tlieiefoie moie than
likely thai, under cnciimstances fa\oiuable to
the growth and development of microbes, the
middle eai is intectod thiough the Eustachian
canal, although it is probable that frequently
the organism gams access through a perforated
membrane These interesting investigations,
luwevci, do not at present give us much assist-
ance in the classification of, or the practical
treatment ot our cases, but it may be hoped
that further knowledge ma> lead to something
of value, at least as to the treatment and
prognosis of proti acted cases
In addition to tho causes tending to an
extension of catairh through tho Eustachian
canal, it must be remembered that eai disease
may be set up by Politzei's bag or the catheter,
used in an improper \\ay 01 under unsuitable
circumstances, and without doubt acute otitis
results not infrequently horn tho careless use
of the nasal douche Fluid may also be forced
up the Eustachian tube when diving or swim-
ming, 01 may pass directly into the middle ear
if there be an old perforation.
KAR ACUTE INFLAMMATION OF THE MIDDLE EAR
485
PATIIOLOG Y —In the early stage of the disease,
and thioughout the course of a mild case, the
catarrh is confined to the superficial layer of the
lining memhiane of the middle car Congestive
swelling takes place, and is soon followed by
exudation of seium and mucus In scveie
forms the inflammation and (dwelling become
more intense, and the deepei penosteal layers
arc involved, while the exudation becomes
purulent m diaractei Tho welling is due to
dilated vessels, along with thn mtoi utitial,
seious, and cellular mfilttation As the case
pioceedu the epithelial layer tends to soften,
and the smface presents a red, soft, gianular
appeal AIICC Pei foiation of the mcmhiano is
likely to tike plucc in a sexeic caso, eithei
fiom the dnect picssmc of the exudation, or
fioni destination of ]>ait of the menibiano
o\\mg to the •uutonrsi of the inflammation
In the mildei attacks the inflammation would
appeal to be limited in its activity to the
Kustac man tube and Uwci purtoi the tympanic
cavity, but in se\eie discs the whole lining
membiane, im hiding tli it of the mastoid cells,
is equally dftectnl \\heii this is the ease the
swelling of the milfoils membmne may easily
Hock the noimal channels of communication
between the vdiioiis pntb of the middle car,
mtoifcium with piopei diainage, «uid thus
leading to if >ton turn of pus, peuostiti-, and
e^on neciosis in the mastoid and attu
SYMITOMS ~ The piominent symptoms of
acute otitis mi'dia aie pain, dt>,ifncss, tinnitus,
with a t.uyiiii! amount of constitutional dis-
turb«incc, as shown by a use of tcmpciatuie,
geneial maluse, nausea, niddmess, and head-
ache, but* these \ uv gieatty auoidma to the
type and su \eiit} of the attack
Pain is usually the hist symptom to attiact
attention It commences as a feeling of dis-
(Oinfoit 01 tension in the ear, which soon
becomes actual pain It is not as A mlc con-
tinuous, but will almost disappcai foi a few
hours, shoitly to leappeai with lenewed m-
tcnsily, and this most iie^uently at night It
may xaiy tiom a dull ache to the most intense
agon}, and to some extent the \iolenco and
fhoiartei of the inflammation may !>»• gauged
by the seventy of the pain A numb hvling 01
actual pain IIIAA ladiatf* OAOI the wholo side of
the head, and it will generally l>c found that
prossuie on the trains, 01 movement of the
diuicle, mcicases the discomfort In childicn
attacks of " eaiache " aic often spoken of lightly
<is if they weie one of the necessaiy ills of child-
hood, but it should bo lecogmaed that* these
aio almost imaiiahly due to a middle ear in-
flammation, and that even in the mildest attack
the hearing may suftci peimauently With the
appeaiauce of a disehaige immediate ichef
gone i ally comes, at any late foi a time
Deafness may be slight at the onset of the
attack, and may not attract much notice for a
day or two, more especially if one ear alone Ixs
affected Sounds may be coirectly lecoguised,
but as if they proceeded from a distance, and
the patient often complaint! that he heais hi*
own voice with almost painful distinctness ami
force As the catarrh extends and the exuda-
tion and swelling uicieas>e, the low* of heating
power becomes more luaiked, until it may be
almost absolute tor external bounds The
tunmg-foik will bo better heard in contact with
the mastoid than when its -vibrations arc con-
voyed through the air on the affected side
Occasionally when the inflammation is of a very
severe typc>, as m some cases of scarlet or
typhoid foM-i, an eaily extension to the labj-
I'Mth takes pbec, causing absolute deafness,
which is hkely to pro-vc moie 01 less permanent
Noises of some kind aie generally b^ard in
the afli'cted oai by the patient, but these seldom
cause the annoyance and distress that tinnitus
often does in chronic ear affections The patient's
attention is piobably ccntied on the other acute
s\, mptoms, and hence he pays less attention at
this stage to the tinnitus However, he often
describes a thumping, beating, or pulsating
sound, synchronous \\ith the heart's action, aa
being piesent, while later on the sound becomes
nifjie steady and continuous, like the escape of
steam 01 the lushing of water Bubbling or
fiac'klmg sounds aie often noticed fiom the
p«ish«igo of a bttlo tin thimijrh the fluid exuda-
tion in the tympanic cavity
Constitutional symptoms aie sometimes
usheied m by a chill or e-sen by a ngoi In
mild uttaiks the tempeiature does not rise
appmuhly, but whun the attack is \eiy acute
the tempeiatme will lAngc fiom 100° to 104°,
Theie is a geneial feeling of uneasiness, loss of
appetite, and possibly nausea, with headache
and <li//mess In people of a neivous tempera-
ment, and specially m children, the general
distin banco is often veiy gieat
The objective signs of otitis consist mainly m
changes in the normal appeal ancc of the
membiane, which can only be detected when it
is caiefullj examined with a speculum and
it 'fleeted light In the stage of «w ute catarrh
the smface of the membiane is of a dull opaque
colour and wanting in lustie In scverei fonus
its cutaneous laxei exhibits maiked injection of
the small vessels, 01 its whole surface may
assume a bright led 01 purplish led colour
When Hcioiib exudation is poured out into the
tj mpanum the membrane tends to bulge out-
waids, and it may not be possible to recognise
the handle of the malleus Sometimes when
the exudation is copious the membrane appears
tiansparent and not icddened, and it is possible
to distinguish thiough ft the presence of a
quantity of fluid, a daik line indicating the level
to which the fluid has icached When the
exudation becomes purulent the bulging mem-
brane vanes in colour from a tinge of red to a
486
EAR. ACUTE INFLAMMATION OF THE MIDDLE EAR
bright red with a yellowish background , or a
yellow spot may indicate the point at which
perforation is about to take place When the
membrane is oodematous it is sometimes not
easy to recognise A small peif oration with the
eye, but if there be fluid in the meatns, to which
a pulsation is communicated, it is safe to asset t
that the perforation exists When e\tensi\e
necrosis ot the membrane 1ms occurred the
position and extent of the perforation can
generally be made out after the meatus has
been dried out The secietion from the tym-
panum may be mucus, serum, pus, or blood, but
more frequently it consists of a combination of
these
The glands behind and below the eai may be
swollen and tondei, and the soft parts cnci the
mastoid may be uxlcuiatous 01 slightly reddened
Facial paralysis is occasionally though raiely
observed in the course of an acute middle eai
catairh from effusion into the Fallopian canal
The most severe cases oi otitis media occui
in the course of attacks oi scailatma, measles,
and diphtheria, and it is probably due to the
organisms piesent in these cases that the in-
flammation is of such severity as to cause lapid
and extensive destiuction of the mombiane, and
often the eaily onset of mastoid 01 other
complications
In otitis associated with tuberculous disease
the symptoms seem to attiact less notice than
usual, because there is generally but little pain
The appeal ance of a puiulent discharge may
be the first intimation that the ear requncs
attention , all the same, these* cases "very icadily
become chronic ones
Influenza is said by some to modify the
symptoms of otitis occurring in its couise A
htemorrhagic form of middle car disease
associated with influenza has been described,
and a tendency to peisistence of mastoid pain
after the local conditions have improved is not
uncommon. The latter is probably a neuralgic
condition due to the well-known depressing
power of the disease Cousideiing the gieat
frequency of so-called influenza, it would appear
that the disease does not tend to cause middle
ear inflammations to any greater extent than one
would expect, in view of the tendency to catarih
of the air passages which accompanies it An
opposite opinion is, howcvei, held by several
writers
RESULTS — The u>sults of acute otitis vary
greatly according to the type and seventy of
the attack In a simple acute catarrh the
majonty of cases tend to recover with almost no
special treatment In catarrh with" exudation
also the result may be — (1) a complete recovery
without perceptible 'changes, (2) recovery with
some adhesions and slight defect in hearing, or
(3) a perforation with purulent discharge
The result of acute purulent inflammation
may be —
1. Complete cure, with healing of the
membrane.
2 Closing of the perforation by cicatncial
tissue and adhesions
3. Continuance of the poif oration with or
without a chronic discharge
4. Certain complications which may be
dangerous to life.
We have already mentioned that facial
paralysis and labyiinthmu deafness may occur
in the course of an acute otitis, mid to these
complications may be added mastoid disease,
polypi, meningitis, ceiebral abscess, thiombosis
of the hiteial sinus, and scpticamna As these
are much rnoie frequently the accompaniment
of clnonic suppmation we shall not fuither refer
to them heie No haid and fast i tile can be
made to decide when an acute otitis should bo
classed as a chrome ease A consideration of
the symptoms will help to decide this question ,
but, speaking very gencially, \vhcn a puiulent
disc huge shows no signs of abating aftei six
weeks or too months undci ti raiment, it may
bo consideied that the case is becoming a
chronic one
DIAGNOSIS.— The histoiy oi the case, taken
along with the s\ inptoms and appeal Alices which
have been mentioned, makes the diagnosis of a
typual case one of no great difficulty It is a
moie difficult mattci, sometimes, to make an
acunatc diagnosis \\hen the appeal ances are
masked by some othei eai aftei t ion, 01 when we
hmo mi pel added some of the more serious
complications which may supencne in the
comse of an otitis media It should be ic-
mcmbcred that pain and deafness, the pioinncnt
symptoms, are to bo met with ui Vanous eai
conditions, and hence it is not suiprising that
the true nature of the case is not always evident
at the first glance Foi example, in fuiun-
culosis \ve find gieat pain and deafness if the
meatus be much blocked by spelling, «ind
possibly a little dischaigo , in nemalgia from
bad teeth we often have acute pain located in
the eai, hypeiomna of the membrane, and slight
deafness, and plugs of A\a\, foieign bodies
pressing on the drum, eczema, and inflammation
of the external meatus may for a time obscure
the real condition Perforation of the drum is
sometimes difficult to detect, but the occurrence
of this condition can generally bo discovered by
inspection of the drum, by noting the secretion,
and if iiccessaiy listening to the sound produced
while air is injected into the tympanum
In certain cases, >vhere the constitutional
symptoms are veiy severe, the ear may at first
escape notice and examination, and typhoid
fever or meningitis may be suspected.
In infants acute otitis is not uncommon, but
the diagnosis is apt to bo overlooked because the
little patient is unable to indicate the seat of
the pain, and the deafness may pass undiscovered.
The general symptoms are often very severe,
EAR : ACUTE INFLAMMATION OF THE MIDDLE EAR
487
including high fevor, restlessness, vomiting, and
even convulsions, before the ear is placed under
suspicion Hurtmann has shown that otitw
media in infants is often associated with in-
testinal disturbances, as indicated by dyspepsia
and casting, and that after puacentesis of the
membrane the temperat uic falls, the distui bance
in the digestive organs disappears, and an m-
ciease of weight follows In any infant wheie
there are symptoms of restless discomfort,
screaming, feveiishness, etc, without eudont.
cause for the same, it is well to wake a careful
examination of the cars for the piesence of a
possible otitis The sevci ity of the constitutional
symptoms is probably in part due to anatomical
peculiarities in the middle car in the child, such
Ah the relatively gieatci si/e and thickness o*
the membiane and the incomplete development
of the bony parts of the middle ear. Measles
and scailet fcvei produce such a largo numbei
of canes of otitis that it is neccssdiy to be on
the look-out foi caily signs of eai tiou\>le, and
by early attention to the thioat and nose to tiy
and lessen the nsk of middle ear affections It
should be remenibeml that some Jiutluuities
con Bid ei the discharge fiom the middle cai in a
ca*e of scarlatina as highly mfectnus It is
not deal, however, ho\v lonn the dischaige may
bo a souice of dangei to others
PHOONOSIS — In estimating the prospects of a
patient suffeiing Jrom acute middle ear cataiih
we must remembci th.it the disease may aftect
the function of the oigan, 01 may pioduce
complications winch may endangei the patient's
health or even his life It seldom happens that
acute otitis leads diiectly to a fatal result, but
the hearing powei is often more 01 less pei-
manently impaiied
In the mild c atari hal tjpes complete recovery
is usually to be expected, but in the acute
purulent attacks the intensity of the sj rnptoms
will generally bear some relation to the course
and effects of the disease Swelling and pain
over the mostoid, continuance of the pain, and
fever, with copious dischaige, make it probable
that tho case will be a protiacted one, \\hilo
rapid subsidence of the fever and other symptoms
after peiforation may bo \iewod in a favouiable
light Needless to say, a patient in a lobust
condition of health is likely to make a quiekei
and more satisfactory recovmy than one who is
the subject of tubeiculosis, syphilis, or general
debility Tho position and size of the perfora-
tion will sometimes influence the com HO of tho
attack, for a veiy small perforation, or one
situated high up, or in Shrapnell's membiane,
may cause tho retention of discharge instead
of allowing it to pass freely away While
necrosis and mastoid abscess seriously protract
tho illness and call foi prompt measuies, in
acute cases they are much moie amenable to
successful operative tieatment than chiomo
cases.
Mild attacks of short duration, often spoken
of as "earache," are not infrequently viewed as
being too trn ml to require any special attention
While they may recover completely without
any after effects, it should be remembered that
not a few cases of auditory defects discovered in
later life can be traced back to foimei apparently
ti iflmjr and neglected attacks of otitis Repeated
attacks of earache, however slight, are likely
sooner or latei to cause damage to tho ear, and
therefore their cause sho'ild be investigated
w ithout delaj
It w always well to give a guarded prognosis
at first as to the healing power If there IB
very marked deafness, and if there is great de
btnutioii of the drum and detachment of the
ossicles, 01 if the labj nnth appears to be sccond-
Hiily affected, there is likely to be more or less
permanent mterfeiencc with the function of the
organ If impiovement commences soon aftci
the cessation of the inflammation, and if this is
inci cased by inflation of the tympanum, a favour-
able result may be predicted with some amount
of confidence
TREATMENT — The remedies to be employed
will depend to some extent on the seventy of
the symptoms and on the stage which the
disease has reached befoio it comes under obser-
vation The objects to be kept in Mew are to
cure the local affection, to dimmish the acute-
ness of the inflammatoiy piocess, to prevent
complications, and to icmove as fai ns possible
the cause of the attack.
Confinement to the house and to a warm
loom is always advisable, and if his temperature
is much above normal the patient should also
bo kept in bed The food should be light and
non-stimulating, and alcohol and tobacco must
be interdicted. The state of the bowels should
be mquiied into, and it is a good rule to com-
mence the tieatment with a Mimll dose of
calomel or grey powclei, to be followed by a
saline purge in tho moinmg In children, it
the skin is hot and dij, a warm bath and a
simple diaphoretic iniUuie may be oideied,
while in cases wheie theic is gieat restlessness
01 loss of sleep it may be necessary to grve
biomide 01 Dovci's powder
In the mild cataiihal stage these lemedics
may be all that is required, but if the case
pioves moie severe it will next be necessaiy to
adopt some measures for the relief of pain Foi
this pin pose two 01 tliiee leeches may be applied
o\er tho tragus and tho maatoid process, or cold
may be applied bj means of an ice-bag or a
Leitcr's c oil Most fi equently, howev ei , w armth
will be found more comfoiting to the patient
than cold, and it should be used in the form of dry
heat — flannel, cotton-wool, or the old-fashioned
hot salt-bag, — while poultices and moist applica-
tions should be avoided A few diops of chloro-
form on cotton-wool, or of some aseptic solution
containing a local antesthctic, may bo tried with
488
EAR ACUTE INFLAMMATION OF THE MIDDLE EAR
advantage, but it is necessary that the medica-
ment should come into actual contact with the
membrane if it is to case the pain. The ances-
thetio action of pure carbolic acid in glycerine,
1 part in 10, has been highly praised, but as a
general rule we have employed the following
drops with excellent results in relieving tho
pain and lessening tho local inflammation : —
ft Cocam hydiochlor gr vj
Acidi carbolici . gi. vj.
Glycenni . . ,"ij M.
Ten drops of this mixture can bo warmed and put
into the car when the pain is troublesome, caio
h'jiiig taken to move the amide backwards and
forwards until the drops have i cached the mem-
brane In addition to tins, (? tuber's medicated
gelatine pioparations, 01 solutions containing
morphine, atropme, lead and opium, and many
other substances, may be used u ith advantage
Mustard and other countei-mitants applied o\er
the mastoid may allay pain, but they also may
mask tho onset of mastoiditis, and therefore are
better avoidud
When these measures fail to gi\e relief m a
shoit while, it may be necessary to perform
paracentesis of the inciubianc The indications
for this piooediue die gieat pain and bulging of
the membianu fioin oxoess of seeiotion Even
v»hen the presence of exudation ib doubtful an
incision may be recommended, for it gieatly
eases tho pain, and heals voiy r.ipully if no
suppurativo condition is found In a <om-
mencing purulent inflannnation, and specially
in scarlatinal cases, it is well to incise early,
for not only is the pain thus alleuatod, but
there is hkoly to be less destruction of the sub-
stance of the membrane than there will be if wo
mait foi spontaneous i up t lire.
Paraccntesis is performed \vith a slender,
spoar-shaped knite fitted to a bent handle, and
•when using this n good light should always
be reflected on to the membianc, anil every
antiseptic precaution attended to The incision
should be of sufficient si/e to allo\v tho fice
escape ot the ret,nnod seciution, and the point
usually selected for it is in tho posterior inferior
quadrant In childien it will generally be
necessary to administer a general anaesthetic,
but in adults this can usually be dispensed \\ ith,
for though the pain is veiy severe it is only
momentary Atter the opening has been made
the meatus should be plugged with stcnlised
•wool, and the cat should not be syimged at all
unless there is an undoubted dischaigo of pus
fiom tho incision
Whenever the acute symptoms have begun to
subside it is \\cll to commence inflating the
tympanum by one ofi* the iccogmsod methods,
\vhethoraporfoiation exists 01 not This has
the effect of opening up tho Eustachian tube,
restoring the normal pressure of the air m the
cavity, and dislodging the viscid secretion from
around the ossicles, while if a rupture has taken
place it \\ill drive tho exudation from the
tympanum into the meatus, from which position
it can easily be removed The inflation by
Politzer's method should be continued for some
weeks, say two or three times a week, in order to
pi event the formation of adhesions, or to stretch
them if they havo ahcady formed When one
ear alone requncs inflation, and this requires to
be done for a long time, the force of the air
douche may ovei -distend the membrane of the
good ear This can bo guarded against by
making the patient press family with his finger
on the tiagus of the sound ear m order to
conn tei act the force of the air, or the Eustachian
catheter may bo substituted for Toht/er's bag.
When the thud stage, that of purulent dis-
charge, has heiome established, * bother after
spontaneous perforation or paiaccntcsis, it is
necessary to syringe the eai with sonic uninitat-
mg antiseptic lotion Foi general use \\M in
boric lotion mill answei best, the meatus being
thoioughly dried out xuth absoibent medicated
\\ool after each occasion It is hardly necessary
to paiticularisc the \aiions lotions that havo
been leconnnended foi this jmipose , it is suth-
cient to say that almost any antiH"ptic lotum
may be used, pioxided \ve keep bcfoio us the
objects to be attained, VMS peifect clean! mom
and diyncss
Tho insufflation of a little finely -povuleied
boiacic acid 01 lodofoim often helps to diy up
the secietion, but AS lien the perforation is small
it should be aA oidod, as it may cause a mechani-
cal obstiuction to the escape of the dischaige
Still, \vhen the perfoiation is of good si/se and
the dischaige has begun to lessen in Quantity,
this method of tieatmcnt is very effective in
finally drying up the seuetion
Along \vith the local tieattnent it is nccessaiy
to attend to any nose or tin oat condition \\hich
may be present Phaiyngitis and naso-pharyn-
geal catairh should be piomptty treated, and it
\vill oitoii do much good to spray the nose \\ith
a mild alkaline solution It must not be for-
gotten that adenoids, with hypertrophied tonsils,
aio the cause of many attacks of acute middle
ear catonh, and the operative ticatment of
those should only bo delayed until the acute
car symptoms have passed off The i em oval of
tho adenoids must be looked upon as one of tho
most important preventive measures against
the rcemrence of otitic attacks
Occasionally pain and s welling ovei the mastoid
may, at a \cry early pciiod, indicate the appear-
ance of a superficial mastoid abscess, and M heii
this is the case it is proper to make a free
incision down to tho bone, and a little behind
the auricle, in order to evacuate the pus It
must be remembered, however, that in such
cases, almost without exception, the mastoid
cells will bo full of pus, and that a minute sinus
communicating with the bupeifrcial collection of
EAE: ACUTE INFLAMMATION OF THE MIDDLE EAR
489
„ i\ iN
BACTBHIOIX>G\
PATUOIOM
pus can be found. The external incision, often
spoken of as Wilde's incision, often gives great
relief to the patient, but it should be looked
upon as only the first step in the operation,
which should include the opening of the mastoid
process aUo If this is not done we are very
likely to find that a permanent sinus results,
and that canes of bone will follow, necessitating
a more extensive operation under much less
favourable circumstances
The diagnosis and treatment of the various
complication** which have boon mentioned as
occasionally occurring in acute middle ear in-
flammation do not require consideration here,
as they aie much more frequently the accom-
paniment of chronic suppuration, to which the
reader is referred
Middle Ear : Chronic Suppuration and
Sequels.
489
490
100
PROGNOSIS 492
TREATMENT 493
COMPLICAI io\s —
(1) Gtanufatioiw 493
(2) Polypi 493
(3) Canfii am? Ntirowt . 491
SUPPURATION OK HIE HFCESSUH KPIIYM-
PAN1CUS —
Jltwhyy 195
Treatment , 495
1*< >sT-Supru«A 1 1\ R SEQUEL.!. —
(1) Dty Perforation o} Memfanwi
Tymjmu 196
(2) A<toe*ion» 196
(3) Catctniou* Dejwts 497
(4) J/yjiettttoiu 497
(5) Fat ml I'malyw . 497
l)isH\sLs ot TUB MASTOID PROCESS —
Anatomy . 497
Mastottf Pentatitn . 497
ati ve Eiulomabtotdi tit, —
(1) Atute . 49S
(2) Vhtonu 499
(3) Povt-Jnfluejiza? tiuppmative Jl/rti-
toiditi* 502
(4) Jle~old\ Mattoiditis 502
Cholesteatoma 502
TUBERCULOUS DISEASE 502
INTRACRANIAL COMPMCAHONS POI LOWING
CHROKIP SUPPUKAIIVE OTITIS MET>I v . 504
Extia-Dwal Access . 504
Pachymemnffitis 505
Suppwrative Pia- Arachnitis 505
Temparo-Sphenotdal Abscess . . . 505
Ceiebellar A faces* . . . 506
Thrombow of Lateral Sinus . 506
Septic Encepltalitts . . 508
CHRONIC SUPPURATINE INFLAMMATION OF THE
MIDDIJC EAR (OTITIS MEDIA PURULENTA
CHRONICA).
SYN — Pyogemc Ot' tu> Media
CHRONIC suppumtive inflammation of the
middle car is m .ihuost dll cases the icsult of
a previous .icute iiinainmatoiy attack The
same astrological factors \vhich play a piomi-
nent pait m the production of acute sup-
pur.\tive middle oar catarrh may consequently
be ranked as active causes in the production of
the chronic type of the disease
Of the moie important affections which fall
"ndor the former heading may be cited the
".tUious c\<intliem«it«i, measles, scarlet fever,
suirUtmal diphtheria, small -pox, ard such
generil diseases as diphtheria, mumps, pneu-
monia, influenza (la tfnPP<.')» pulmonary phthisis,
typhoid fcnci, main 1,1, biouchitis, Brifjrfit'a
disease, cerebro-spmal meningitih, etc
The extension of ( ataiihal affections from the
nose, the pharynx, and the naso-pharynx plays
also a piomineut pait in the production of
ticute middle eai suppuration, and hence in
many ca&es in chiomu suppurative attacks also
Many punt -nasal ^To^ths, ewpecially post-
n.isal adenoid vegetations, pioduce such a
degree of Kustachian obstruction as to interfere
A\ith the nonnal phybiolugical action of the
tube, and are responsible in laigc numbers of
cases not only in causing acute attacks, but
also in keeping up such a degree of irritation
fis to present resolution, and so in promoting
chiomcity
Causes actmg upon the meinbrana tympam
fiom \\ithout, <?</ di aughts, the entrance of
\\ater (especially sea- \\atei) iiitxj the extcinal
.uiditoiy meatus, 01 into the middle ear from a
too foicible employment of the nasal douche,
inj unes (blows, concussions, etc), the extension
ot a chionic inflammation of the external
auditoiy meatus (\Valb), by at times pioducmg
acute mflaunnatoi) atticks, aiealsocontubutory
elements in the- pi od action of chiomc suppura-
ti\e catarrh
In tuberculous disease of the middle oar, the
pioeess is legaidcd }r> most authoiitics as
assuming a iluonic type ah initio, that is to
say, sthcmc symptoms aie absent, and perfora-
tion of the membiana tympam takes place pain-
lessly, a disc h.irge fi om the ca\ ity of the middle
cai being piobably the first indication of the
piesence of the moihid process
Tt is doubtful if, tuberculous lesions cxcepted,
the chronic type of the disease is ever observed
without there having been at some period an
acute, 01 at least a semi-acute stage present
In diabetic patients l*us preliminary acute
stage may be of veiy short duration, the un-
favourable effects of diabetes upon the tissues of
the middle car being \\e\\ lecogmsod
^Etiology in Infants — Suppurative middle
490
EAR: MIDDLE EAR, CHRONIC SUPPURATION AND SEQUELS
ear disease, botb acute «uid chrome, is more
frequently met with in children than in adults,
the proportion being 70 to 30. Various factors
are responsible for this. In the first place the
exanthemata, which are prolific sources of ear
trouble, are more commonly met with m children,
as are also affections of the lymphoid stiuctures
of the upper respiratory tract, eg. enlarged
tonsils, naso - pharyngoal adenoids Dentition,
congenital syphilis, and catarrhal affections are
also responsible for the production of otitis media
in many infants and young children
Tuberculous disease of tho middle ear and
adjoining mastoid colls is also comparatn el)
common, especially amongst the childien of the
poorei classes of our large cities.
Purulent disease is also at times met w ith m
the middle ears of now-born infants, and may be
duo to an abnormal metamorphosis of tho em-
bryonic mucous tissue which exists noinully, or
to the passage into the middle cat of hquoi
amnu during forced Attempts at respiration
In children acute attacks of middle car sup-
puration arc at tnres ushered m by symptoms
of great gravity In fact, until a dischai go ii om
the middle ear takes place such cases ate fre-
quently diagnosed as inflammation of tho mem-
branes of the brain The practical difficulties
encountered in successfully treating acute in-
flammatory affections of the middle car in
childhood probably go far to explain why so
many cases pass into the chronic stage
Predisposing Causes — Among the most im-
portant predisposing causes may be mentioned
hereditary tendency, the possession of the so-
called atrumoiiH, tubeiculous, or syphilitic
diathesis, the presence of naso - pharyngeal
disease, especially post-nasal adenoid vegetations,
and the existence of some pie-existing middle
oar affection which, having become latent, is prone
to bo stirred up to icne\\ed activity undei the
influence of certain unfavourable circumstances
i%men«* of the Middle Ear usually involved
—Chrome purulent disease most usually attacks
the mucosa lining the Eu&tachian tube, and the
atrium of the middle eai In certain cases it
may attack tho mucous membrane of the
recessus epitympumcus (attic), and remain
localised in this portion of tho middle car for
varying periods Jn the later stages of chronic
purulent otitis media imolvomeiit of the mucosa
lining the mastoid antrum and the adjoining
mastoid cells may take place
Certain anatomical peculiarities in tho middle
cars of young children deserve consideration on
account of their practical and clinical im-
poitance
Thus the membrana tympaui occupies a much
more horizontal position than it does m adults,
and is also relati\ cly thicker and larger. Hence
m the examination of the middle ear of a child the
auricle should bedraw n downwards and somew hat
forwards, m tho adult upwaids and backwards
The Eustachian tube in the young child is
shorter, of somewhat larger calibre, and more
horizontally situated than in the adult, and
hence acts as a somewhat better drain, and is
more easily inflated The mucosa lining the
middle ear is frequently in intimate association
with the dura by means of a process of fibrous
tissue running through the unossificd squamo-
petrosal fissure.
Tho mastoid or tympanic antrum is, however,
of large size, and is more superficially placed
than in the adult The lateral sinus in }oung
children is separated from tho mastoid cells by
a bridge of bone which is lelatively thickei than
in the adult.
BACTERIOLOGY OF CHRONIC SUPPURATIVE Ix-
FLAMMAIION — The role played by micro-organ-
isms in the pioduction of chronic suppurative
middle car disease is a most important one
Whether micro-organisms aio to be looked upon
as the actual factors in the pioduction of middle
ear suppuration, or only as incidental to it, is at
present a moot point, but that they play a
prominent part, not only in the disease itself,
but also in the production of its complications,
is undoubted Aenal contamination ot the
cavity of the middle car may icadily take place
either by way of the Eustachian tube or extei-
nal auditory meatiw Putiefactive bacilli aie
present in largo numbers in fa-tid discharge
fiom tho middle ear, and are absent in noii-fatad
discharge, and it is a noticeable and important
f.ict that many cases of what are pnmarily
acute catarrh.il inflammations of the tympanic
niuco&a become puiulent only after perfoiation,
and hence aciial contamination, has taken
place. •
The puncipal oigamsms found m purulent
discharge from the middle ear arc —
(1) Staphylococcus pyogcnes albus et aurcus ,
(2) streptococcus pyogenos, (3) pneumococcus
(Fracnkel), (4) pneumo-bacillus (Fnedlander),
(5) bacillus tuberculosis Furthei remarks
regarding the lelative fiequency and import-
ance of these micro-organisms will be found on
page 484
Other organisms, e y bacillus tennis, bacillus
pyocyaneus, staphylococcus cereus albus, etc,
ha\e also been disco\cred in dischai ge from the
middle car, but do not apjrear to have the same
causal relation as those previously mentioned.
PATHOLOGY — In tho initial stages of acute
suppurativo middle ear oatarrh the characteristic
features are distension of the tympanic blood-
vessels with outpouring of sccietion, and bub-
sequent extravasation of leucocytes, partly into
the cavity of the middle ear, and partly into
the substance of its mucous membrane In
mild cases large quantities of mucus are ciuded
into tho middle ear. In children the exudation
luid.
the inflammatory process becomes chronic
this small round-celled infiltration results in the
EAR: MIDDLE EAR, CHRONIC SUPPURATION AND SEQUELS
491
formation of young connective tissue, \vith con-
sequent interstitial thickening of the tympanic
mucouH membrane Accompanying these changeb
in the deopei layers of the mucosa, the epithelial
covering becomes detached, leading either to
areas of ulccration, 01 to the production of
ocdematous buds of succulent granulation tissue
As the ulcerative process extends, the under-
lying bone becomes exposed, and ultimately
either carious or necrotic In certain cases
small hyperostoses result Almost every case
of chronic suppurative catanh is accompanied
by perforation of the membrana timpani,
through which the secretion from the middle
ear escapes into the oxtemal auditory mcatus
The nritation caused by this outflow ing becietion
loads to a piling up of epithelial cells upon the
margins of the peifoiatiou, so that in genuinely
c hi onic disease the edges piesent a pale, callous,
and indurated appeal ance Thiough the open
perforation tlio succulent mucosa is to be seen
at times bo lax and flabby as to protiude into
the external auditory meatus
As a result of this chionic mflammatoiy pro-
toss adhesions may take place either between
the membiano itself and the mucosa covering
the pars promontoria, or between the individual
ossicles binding them together, and so interfering
senoubly \\ith the tiansmission of bound waxes
()i again the inflammatory process may spread
to the labyrinth, pioducmg a tiansient hvper-
tcmia, or in more severe cases an attack of
purulent lab} imthitis, ending in complete de-
struction of hearing (panotitis)
In ceitain cases a geueial <itiophy of the
mucosa ensues, charactcnsed by <i thinning of
the memtnana timpani, and a disappcaiance of
the normal elements of the mucous membrane
Accompanying these changes xuthm the middle
ear are changes of an almost similar natuie in
the mucosa lining the Kubtachian tube, ? </
swelling and oedema, enlaigemcut of the mucous
glands, bhcddmg of the epithelial lining, etc
As a icbiilt considerable stenosis of the tube
may ensue
SYMPTOMATOLOGY — Subjective tfymptwi* —
Pain, x\hich is usually such a piomment featuie
m acute attacks, is usually absent in chronic
cases, 01 occui * only as the precursor of some
serious complication, or as the result of tension
due to obstructed outflow of secretion from
blockage of the perforation by masses of granu-
lation tissue, polypi, sequestra, stenosis of the
meatus, etc Acute pyogemc attacks giafted
upon a chronic basis occur fiom such causes as
exposure to cold, the entrance of water into the
ear, etc , and aie accompanied by pun of greater
or loss severity In chronic cases, when dull,
deep-seated pain is complained of m the head, a
suspicion of the involvement of the meninges,
the cerebral or cerebellar hemispheres, or of
the great venous sinuses should be enter-
tained.
In chronic cases when extension to the
mastoid process takes place pain becomes a
prominent symptom. In debilitated and anaemic
subjects pain referable to the brandies of the
fifth neive is frequently complained of, and calls
foi treatment upon geneul principles
Incontinent of Hear my — The degiee of im-
pan ment of hearing m chronic cases % aries x\ itlun
wide limits Thus it may be nearly noimal in
one case, and almost destroyed in another
The biro of the pcif oration appears to beai
little if any relation to the existing rlegice of
deafness Thus utses occui \\here with almost
complete destruction of the membianc a laige
percentage of healing powe.* is ictaiued, and
others Alien, the heating poxvei is almost gone,
even when a minute perforation exists.
In ta&us where the perf oration is situated in
Shiapnellb memhiane, the healing power may
be piactically unaffected The piesence of a
peifoiated membiane contnbutes probably only
to a small extent to the existing degiee of deaf-
iiebb Othei factoib xvlndi play an almost more
itnpoitant role aie —
(1) The presence of secretion in the middle eai,
pre\entmg tianhmis<*ion of bound waxes, and
hampering the action of the ossicula auditis
("2) Adhesions between the membrane and
the adjacent walk of the middle ear, between
the ossicula thcnisehes, 01 between the foot-
plate of the stapes and the maigms of the
fenestra ovalis
(3) The pieseme of an unduly a'dematous 01
granulai mucous membiane lining the lavum
t} mpaiu
(4) Loss di paitial destruction of one or more
osbicles, leading to a want of continuity in the
obsicular ch.un
(3) Secondaiy implication of the labynnth
Tinmtit* — Subjective noises aic not ftequent
in chronic suppuiatrve catanh xvith perfection
When the} do occui, they aie usually due
cither to adhesion 01 to indiawmg of the
ossiculai chain, to the piesbino of pent-up
secretion upon the fenesti.e, or to an accom-
panying affection of the labyrinth.
Vet tit/o ib <ilbo, not as a rule, complained oi,
and xx hen present is due to the same causes as
aie responsible foi the production of tinnitus
Disturbances of ta*te and t,mell, especially of
the formci, aio fiequent, and aie due to injury
to the chorda tympani nei\e in its passage
thiough the middle eai, and to the occasional
passage of putud secietion along the Eustachian
tube into the phaiynx
Objective AjujHtuanm — The most important
indication ot chionic suppuiative middle ear
disease is the presence of a dischaige This
discharge may bo so .ihmidaut as to flow from
the external auditoiy meatus, or may exist in
such small quantities as meiely to form a film
over the loinams of the membrana tympani
Its consistence, likewise, vanes from a thick
492
E\U MIDDLE EAR, CHRONIC SUPPURATION AND SEQUELS
creamy pus to a thm icborous and imtatmg
fluid. At times it is mixed with much mucus,
and is consequently tenacious and stringy , at
other times it is blxxl-stamed, especially when
granulations or polypi are present Frequently
it has a peculiarly offensive odour, when second-
ary canes or necrosis coexists At times it has
n bluish colour impaited to it by the presence
of the bacillus pyocyauous, at other times
n greenish colour, from the piescucc of the
bacillus fluorescens It may contain numbers
of white, glistening epithelial cells, \\here
cholesteatomatous masses are present in the
atticus or tho mastoid autrum, and in cases of
caries of the unrounding bony walls, may be
mixed with spicules of dibintegiatmg bone
Perforation of Memlnmie — Upon examination
the membrane -will l>e found to be perforated
Usually only ono peifoiation exists, at times
two, and occasionally even three, Are to be seen
The site of the perfoiation \aries much
Most frequently it is situated in the lower
segment of the mcmbiane, but may bo found
in any pait When mtuateil m Shiapnoll's
membiane it is associated with snppurative dis-
ease of the recesHUH epitympanicus , and when
in the postenor pa.it oi Shrapnrll's mcmbiano,
it is said by some authorities to be an indica-
tion of suppurativo inflammation of the lining
membrane of the mastoid antrum
The size of the pcifoiatum vauos within wide
limit* It may be so hmall as to be dibceimblo
with difficulty, at othoi times it may pi actually
mvoh e the w bole of the membrane However
large the perfoiation may be, it m laie to find
the membrane absolutely dostioyed Usually a
small ring around the area ofr UH attachment is
left Th.it poition of the membiane above the
level of the short process of the malleus is also
usually pieservcd
The condition of tho edges of the perforation
gives in a rough way sonic idoa of the duiation
of the suppniative piocess Thus, in compara-
tively iccent cases the edges have a fairly vas-
cular pinkish appe.ii ance, \\heie.is in genuinely
chronic casos they present a thick, indurated,
and irregular whitish outline In exceptional
cases the membrane may bo impeiforate, the
discharge escaping through fistulous tracts in
the postero-supenor meatal wall communicating
with adjacent mastoid cells or by way of the
Eustuchuvn tube
The diagnosis of the existence of a perforation
is usually made by inspection of the membrane
under suitable illumination In coitain cases a
pulsating spot will bo noted, an almost sure
sign of the presence of a perforation By means
of a Siogle's pneumatic speculum it is possible to
draw secretion from S,he cavity of the middle
oar through the peiforation If imperfoiate,
suction by means of this speculum causes a
movement of the whole membrane, whereas if
perforated, suction produces no movement what-
ever. Again, by means of the Valsalvan experi-
ment, inflation with Pohtzer's bag or the
Eustachian catheter, secretion can be blown
from the middle ear through the perforation, or
in cases of a dry condition of the middle ear
various sounds will be heard as air blown into
the middle emerges through it Thus, in cases
of small perforations the sound is shrill and the
note high-pitched
PROGNOSIS — The question of prognosis has to
be considered m reference to danger to life,
cessation of discharge, and improvement in
hearing1 The duration of the disease, the
particular part of the middle ear which is im-
plicated, and the underlying cause of the tiouble,
afford valuable information m estimating these
probabilities With legard to the dan^ci to
life, it may be said that so long as suppuiative
catarrh oi the middle ear is present, so Ions* is
the patient liable to the occurrence of vaiiuus
septic complications, any one of which may
prove fatal Even in com{ arativoly simple
casoH soveie nitiacianial complications may
suddenly supcivone As a general rule, the
lonijci the disease has lasted the grcatci is the
risk of bone complications, and hoiicc the greater
the nsk of srptic absorption Disease within
the rcccssus epityrnpamc'us, esi>ccially when
accompanied by thij presence of a small peifoia-
tion, is undoubtedly more prone to be followed
by intiactama.1 complications than wlu»u situated
withmtlio atimm and when a laitfe perfoiation
is present AVhen the result of scailct fcvci,
scarlatinal diplitheiia, tuberculosis, or syphilis,
the prognosis is not so good as when it u
secondary to catarihal lesions, naso-phaiyugeal
disease, etc. "
The probabilities of a complete cessation of
the discharge aio much greater if the disease l>o
confined to the atrium than when it implicates
the rceessiui epitympamcus oi adjoining mastoid
cells In this lattei situation bone lesions aie
much more frequently met with, and efficient
drainage is much moie difficult to secure The
continuance of foetid discharge, after prolonged
antiseptic treatment, is btiong presumptive
evidence of the existence of an accompanying
bone lesion When the discharge is tenacious
and ropy, chromcity is apt to be favoured
Improvement in hearing may bo anticipated
in those cases where, after inflation with
Pohtzer's bag, the range of perception of sound
is at once increased, and especially when it is
maintained for some hours, or even days
When, howevci, tree inflation of the middle
ear pioduces no effect upon the hearing power,
and when bone - conduction is diminished, the
probabilities are that, even if all suppuration be
arrested, theio will be little or no increase m
audition. Where adhesions bind tho membrane
to the promontory, or the ossicles to one another,
1 The relation to " Life Insurance" will be considered
under that heading
EAR: MIDDLE EAR, CHRONIC SUPPURATION AND SEQUELA
493
their division may be followed by improvement,
and even in cases where there is an accompany-
ing diminution m bone - conduction, which,
under such circumstances, is probably due to
temporary increase of mtra-labynnthme tension
TREATMENT — To successfully treat chronic
suppurativo middle ear disease the guiding
principles should be the obtaining of (1) efficient
drainage, «ind (2) surgical cleanliness
(1) To secure fiee diamage, bniall pcifoiti-
tions may have to be enlarged, especially when
situated in the upper segments of the mem-
brane Tufts of granulation tissue and polypi
demand early removal Due attention should
also be paid to securing a free action of the
Eubtachian tube by the icmoval of post-nasal
adenoids or othei post-nasal growths, and by
attention to any moibid condition of the nasal
01 pharyngeal mucosa likely to keep up a
catarihal state of the surrounding tissues
To cloanso the cavity of the middle eai
the following plan may be adopted \\ith
advantage -
(1) Inflation of tin* middle eai
(2) Syringing of the external meatus with a
suitable antiseptic lotion or \\ith steiihsed
water
(3) Suction by means ot Sugle's speculum
(4) Inflation again
(.">) Syringing 01 dicing \\ith an .nitiseptu
wool
After caieful cleansing, one of several method*
may be adopted with the idea of restoung tin*
tympanic mucosa to a health} state Those
methods are. —
(1) The employment of fluid remedies in the
toiin of ctrops 01 lotions
(2) The dry method of treatment by means
of iiiHufiLition of finely puh erised po \\deis
(3) The aspnation method by means of gau/e
tampons
Fluid remedies, from the fact that they aic
easy of application, aie the most frequently em-
ployed To cnsuie their successful action tho
lotion introduced into tho external meatus
(after preliminary cleansing) should be allowed
to remain in contact with tho tissues for iiom
ten to fifteen minutes two or three times daily
Such drugs as carbolic acid, rcsoicin, sulpho-
carholate of copper 01 of zinc, alum, nitrate of
silver, boracic acid, acetate of lead, bichloiide
of mercury, pcioxido of hydrogen, etc , may be
used with advantage So long as a peif oration
is open, it is advisable to keep a film of anti-
septic wool or gauze in the meatus, to pi event
aerial contamination of the part, to waid off
cold, and to assist in drainage.
The insufflation of powdcis (boric acid, lodo-
form, curopheu, aristol, etc ) is useful in cases
where the perforation is large and where the
amount of dischaige is small. After caictul
cleansing and drying of tho part, the powdei
should be insufflated by means of one of the
many insufflators in use for such a purpose, and
should bo repeated at least oiuo m every
twenty-four hoius until the discharge has
practically ceased
Where small perforations exist, or \\herc the
dischaige is copious, this method of treatment
is ( ontta-indicatcd
The employment of gauze tampons acts
admnably m many cases When a strip of
such a gauze as lodoform or double cyanide is
cjuefiilly packed into the external meatus, and
so down upon the poif orated membrane, the
capillaiy action of its fine fibiils sucks up dis-
charge from the middle ear and so acts as a
continuous diam, besides protecting the parts
Irom aenal Contamination — a most important
piopeit\ Smh gaiue tampons should bo m-
tiodmed a,s often as the} get soaked The}
ire most suitable in cases whcio the amount of
disthaigo is not vciy copious, and aic unsuitable
in acute cases and cases when* there is an
accompanying otitis cvtciua
COMPLICATIONS OF CHRONIC SUITLRATIVE
MIDDTE EMI DISEASE
G'lawilaltoui — These aic hypeiplasticgiowths
lesultmg fiom «in over-giowth of the* tissues of
the tympanic mucosa, the icsult of long-con-
tinued congestion They vary in size from
nimiito exciesiences to masses winch block up
the middle eai, pi ot rude through the peif orated
membiane, and conceal the edges of the por-
ioiatmn m whole 01 in pait, and aic frequently
associated with an undei lying carious condition
ot some poition of the tympanic parietes
When hanging fiom the tegnien timpani they
must be talc-fully distinguished fiom granula-
tion tissue masses attached to the dura mater
and piojpctmi» into the cavity of the middle car
tlnough canons defects in its bony loof.
1'ofyjn icsiilt also fiom long-continued imta-
tion, the consequence of chronic congestion or
siippuiative inflammation of the tympanic
mucosa The} may be classified as follows —
(1) Mucous, (2) hbious, (J) my \omatous,
(4) automatons , (3) malignant
(1) The mucous \aiiety is by fai the com-
monest 1 oim of polypus met with In size such
months vaiy immensely, being at times quite
small and nodnlai, at other times occupying the
whole of the oxteinal auditory meatus, conceal-
ing the mcmbiaue entnely fiom view, and even
piojecting cvteinally Microscopically they
consist of numuious small lound cells, connec-
tive tissue tibies, tlun-w.illed blood-vessels, and
glands Tow aids its point of ougm the polypus
is co\eied by columnar ciliated epithelium, but
towards the suifacc these columnar ciliated cells
arc replaced by a stratified epithelial layer
Polypi may be attached to the pane tea ot the
middle car by one or two roots, and usually
spimg from eithci the posterior or the inteinal
wall At times they anse from the edges of a
494
EAR • MIDDLE EAR, CHRONIC SUPPURATION AND SEQUELA
perforation or from the surface of the membrana
tympani itself. Occasionally they arise from
the lining membrane of the auti um or mastoid
cells, and more rarely still front the walls of
the external auditory meatus, in which Utter
case they icsult from an otitis externa of the
para ossea
(2) Fibious polypi are much less frequently
met with, and consist of dense layers of fibious
tissue coveted by tessellated epithelial cellb
Ramifying thiough the fibrous strands are
small bloodvessels They originate from the
periosteum lining the tympanic cavity 01 fiom
that of the external auditory meatus
(3) Myxomatous polypi aie distinctly laic
and have the structure of gelatinous mucous
tissue.
(4) Angiomatous polypi consist of a dense
interweaving of blood-vessels supported by a
fiamowork of fibious tissue coveicd by stoati-
fied epithelium They aie consequently veiy
\ascular and bleed freely when removed
(5) Malignant polypi may be cithei of a
earcmomatous 01 saicomatous structure If
the foimer, they may result as the outcome
of prolonged suppuiative middle eai disease
They are characteiised by a maikcd tendency
to slouching and to spontaneous homiorrhage
They also rapidly invade adjoining bony struc-
tures, producing A cry extensive destruction of
tissue
Sarcomatous poljpi may on«inate uithm tho
middle car, and uhen appeal in&r cxteinally may
present all the appearances of benign gio\vths
Then lapid lecurrencc aftei iemo\al and then
tendency to hpontaneous linnnoiihage should
excite suspicion as to their real natuie At
times they anse fiom the hbious sheath of the
auditory nerve or from tho hbiuiis stioma ot
tho dura matei, and invade the middle ear in
then progioss to the suifaee
In the treatment of lennjn nural polypi the
primary indication is to treat the inflamed
surface fiom which they originate When
small, soft, and ocdomatous, then fuither pro-
gress may be checked by the local application
of astringent 01 caustic prepaiations Such
drugs as pel chloride of non, nitrate of silvei,
chromic acid, 01 ti ichloracctic acid may be em-
ployed \uth advantage, the ding being eithci
fused to the end of a suitable aural probe or
applied m solution upon the end of a cotton-
armed probe To expedite their destruction it
is often advantageous to ciush them with an
aural crush foiceps, or nip as much of tho
growth away as possible \vith a suitable forceps,
and then to apply some caustic drug to the so-
called root or base When sufficiently large, it
is advisable to remove as much of the giowth
as possible by means of a suitable aural snare,
the loop being made to grasp the pedicle as
near to its base as possible. Hremorrhage,
which is at first fairly profuse, is readily con-
trolled by moans of warm syringing or by
tampons of some antiseptic gauze. Repeated
applications of caustic, e g chromic acid, should
be made to the base of the growth until its
disappearance has been assured Astringent
lotions, especially when containing rectified
spirits, are valuable adjuncts in the subsequent
treatment of the case, acting as they do by
dehydrating the tissues and causing the coagu-
lation of then albuminous elements
The treatment of malignant polypi is, un-
fortunately, far from satisfactory Occasionally
sarcomatous growths originating within the
cavity of tho middle ear have been successfully
eradicated Tho tendency, however, of carci-
nomatous growths to invade the neighbouring
bony structures makes operative interference
very undesirable.
Canes ami jfrcrons — As the result of pro-
longed suppurative inflammation of tho mucous
membrane lining tho tympanic cavity, or as the
icsult of inflammation of the peiiostcum covei-
ing the mastoid process, caries or ncciosis of
the suriounding bony parietes may ensue
Usually these affections of the bone commence
in early life, and are frequently associated \uth
an underlying tuberculous process Large
portions of tho temporal bone may become
neciotic and may be exfoliated Thus sequestra
containing tho whole or pait of the cochlea, the
annulus tympauicus, or posterior \vall of the
mastoid process, are by no means infrequently
met AHth in cases of piotracted suppurative
catarrh
In the mastoid region fistuloun tracts may
lead to the interior of the inastoid cells, 01
may lead from the posterior wall of the antrum
into the gioove foi the sigmoid sinus Tho
surrounding bone is commonly discoloured and
softened The bony walls of the aqueductus
Fallopn are pi one to be affected, leading to
exposure of the tacial nerxo and consequent
facial paialysis In cases of attic suppuration
the outer \vall of the recessus epitympamcus is
frequently softened and eroded The ossicles,
moic especially the malleus and the incus, are
also frequently found to be carious, and in
severe cases of nnddlo car suppuration are prone
to become spontaneously exfoliated In tuber-
culous cases the whole of tho interior of the
mastoid process may become broken down,
softened, and caucus, a moro shell of bone re-
maining The inner wall of the middle ear
(tho pars promontoria) is also frequently im-
plicated, leading to exposure of the contents of
the internal ear. The posterior wall of the
external auditory meatus may also become
affected, in which case its cutaneous covering
becomes swollen and infiltrated. Springing
from its carious surface are small masses of
exuberant granulation tissue.
Tho indications of canes and necrosis are
subjective and objective. Pain may be present,
EAR: MIDDLE EAR, CHRONIC SUPPURATION AND SEQUELS
495
and if so, is usually deep-seated and of a peculiar
boring nature. Complete loss of hearing may
result in those cases \vhere the structures of the
internal ear have become secondarily affected
Vertiginous symptoms and tinnitus are also
frequent under similai circumstances
The main objective indication is the fact that
the carious 01 necrotic bone may bo soon or folt
with a piobo The presence also of exuberant
gianulation tissue masses of a vascular nature,
and showing a marked tendency to lecuirence
after icmoval, is of itself strong picsumptive
evidence of an undoi lying carious lesion The
penauncular glands also become enlarged at an
early period, especially in tuberculous cases
The accompanying dischaigc fiom the middle
eat has also, as «i rule, a peculiarly offensive
odour, and may contain spicules of bone, which
may be felt with the fingers It is also at
times blood-stamod, o\cn wluni no granulation
tissue is appaicnt
SUITUUATIVE DISEASE OF THE RECESSUS
En MM PAN ICUH ( Amr)
Suppuiation in this legion is held by some to
be merely an extension of a generalised pmulcnt
inflammation of the ca\um tympani, by otheis
to bo secondaiy to a pinnaiy inflammation of
the mucosa lining the mastoid antium, or to the
extension of such moibid processes as cc/ema 01
turuncnlosis of the exteinal auditory moatus
(«SV<? diagram, p 456 )
Whatever its actual aetiology may be, the
fact remains that disease in this situation is
peculiarly in ti actable to ordinary methods of
tieatment The numerous folds* of mucous
membrane which exist in the atticus tend to
prevent the free escape of pus, whilst the fre-
quent shutting off of this region from the
geiicial ca\ity of the middle eai as the icsult
of mflammatoiy adhesions explains the useless-
ness of attempting to \vash out the part ptt
tnbam The fact also that the accompanying
perfoiation of Shiapncll's mcmbiano is situated
high up upon the surface of the membrane, and
is also frequently xeiy small, servos to explain
the difficulties which attend the fiee escape of
pus fiom the pait The head of the malleus
and the body of the incus, being thus constantly
bathed in puiulent exudation, are prone to
undergo carious degeneration The <idjacent
bony pane tea also frequently become affected,
exfoliation of portions of the annul us tympamcus
or outer wall of the attic occasionally taking
place
Perforations of the anterior part of the mem-
brana flaccida are most likely to be associated
with a moibid condition of the nose, the
Eustachiau tube, or the tympanic cavity,
central per foi at ions with disease of the external
auditory ineatus, and perforations in the pos tenor
segment of the membrane with disease of the
mastoid antrum.
Symptoms of Attic Disease — The objective ap-
pearances consist m the presence of a perforation
(usually small) in either the anterior or postcnoi
segment of Shrapnell's membrane, purulent
secretion oozing from the part, and m the fre-
quent presence of caries of the head of the
malleus and body of the incus or of the adjacent
parictcs, at times visible to the eye, but more
frequently to be detected by means of a delicate
probe Buds of granulation tissue are also
frequently to bo seen protruding through
the pcifo ration into the external meatus, and
.ire usually found to be springing from carious
foci
Sulyectwe ifywi/rfoww — Pain is frequently
piesent, espeiully when retention of secretion
takes place from blocking of the perforation by
buds of £>i .initiation tissue, cholesteatoinatous
masse, small sequcstia, etc
Tinnitus and vertigo may also be complained
of, and rehiilt from mci cased labyrinthine tension
duo to pressuie of inflammatory products upon
the foot-plate* of the stapes or to a secondary
congestion of the labynnth
Treatment — In oidci to efficiently cleanse the
iccessus epitympanicns snmo form of mtiatym-
pamc syiinge (Hartmann, Pritehaid, Milligan)
should bo used, the end of the syiinge being
passed well into the attic undei illumination
After thorough cleansing various medicaments
may bo injected into the pait by means of
specially constructed mtiatympamc cannulie
(Blake, Milligan)
Where the accompanying perforation is very
small it 111.1} bo enlarged with advantage In-
sufflation of antiseptK po\v dci s (Bczold, Gomporz),
tamponadmg ((Jruber), and resection of the
outci wall of the attic (Polit/er, Schwartze) by
means of specially construetixl forceps, have
boen recommended by xanons authorities
The ossicnla auditus, if carious (and where
local applications after a reasonable trial have
failed to arrest pmulency), should be excised
By the pel formance of ossiculoctomy not only
.110 definite canons foci removed, but impioved
drainage is effected and better access obtained
foi subsequent lot al medication After thoiough
cleansing of the meatus and the instillation of a
strong solution of cocaine, the patient being
under tho influence of a geneiul aiuesthetic, the
membrane, or its lemains, is detached by means
of a circular illusion The tendon of the tensor
tympani, if still intact, is now divided close to
its insertion into the bony process of the malleiib,
aftei which its supenoi ligament is also divided
by a fine knife By means of a delicate incus
hook (Krotschmann, Politzcr) the incus is
brought down, and tho incudo-stapedial attach-
ment separated, when with a fine snare or with
a strong pair of augulai forceps the two ossicles
are removed In cases where the incus has
already disappeared as the lesult of prolonged
suppurative inflammation of tho tympanic
496
EAR: MIDDLE EAR, CHRONIC SUPPURATION AND SEQUELAE
mucosa, tho malleus may be readily excised by
means of Delstanche's extractor du marteau.
As a rule the stapes, even in cases of long-
continued suppurativo disease of the middle eai,
retains its vitality This is to be explained
from the fact that it receives nouiishmont from
two sets of blood -\ossols — labyrinthine and
tympanic — whilst tho malleus and incus are
dependent upon one set only, viz tho tympanic
Its removal has, howovoi, been recommended
under certain circumstancos by Kessel, and
several Amencan confreres, notably Jack of
Boston, have recorded suipiisingly good results
following its excision
Whon parietal caries coexists careful curette-
nient by moans of delicate spoons or culottes
(Lake) may be attempted The results of ex-
cision of the ossicula are in many cases highly
satisfactory, vertiginous symptoms being often
entirely relieved and purulency arrested In
those cases, however, where purulency continues
unabated, tho indication is that deep-seated
canes coexists, necessitating the peifoimanco ot
a radical mastoid operation Deep-seated caries
may, however, bo very difhcult, if not impos-
sible, to diagnose with certainty It may be
suspected in those cases of chronic foetid middle
ear suppuration which do not yield to ordinary
methods of treatment, also where tufts of
granulation tissue reappear constantly after
removal, and when deep-seated pains are com-
plained of in and aiound tho middle car.
I'O&T-SUPPURATIVE SlfitJUKL^
Dty Per/oration of tfte Af emit ana Tympani
— When purulcncy h.is come to an end, eithei
spontaneously or as the icsult of efhcient
treatment, a diy perforation of the membrana
tympaui frequently remains In compaiatively
recent cases such perforations have sharply
defined, thin, and somewhat vascular edges , in
cases of old standing tho edges present a callous
and indurated appeal anee from tho presence of
epithelial proliferation
Such open per f 01 at ions aio a constant menace
to the mtegnty of the stiucturcs within the
middle ear and to the life of the individual
Attempts should therefore be made to induce
cicatrisation In louent cases this may be
effected by stimulation of tho edges by the
application of such agencies as nitrato of silver,
dilute chromic acid, tincture of iodine, etc. In
genuinely chtonic cases the application of
tnchloracctic acid (Okounoti) will bo found
most efficacious, acting .is it does by removing
all dry and indurated epidermis
Borthold's myrmgo-plastic method may also
be tried
Multiple incisions Across and at right angles
to tho edges of the perforation, or a circum-
ferential incision, will be found capable at times
of starting a healthy reaction and subsequent
cicatrisation
In addition to such local applications, packing
the meatus with some antiseptic gauze and the
maintenance of rest to the organ will be found
to assist the process of repair.
When cicatrisation of the membrana tympani
cannot be secured, and where there is a marked
defect in hearing power, tho employment of an
artificial drum frequently yields excellent re-
sults No data are, howevei, forthcoming to
indicate the cases in which its employment is
likely to be attended with success. The mem-
branes most in use arc those suggested by
Toynbee and Yoarsley Of the t\vo the latter
will be found to give the best results in tho
majonty oi cases, and its employment, if reason-
able caio be used, is unattended with risk
Artificial membranes should be used only in
those cases whore suppuration has actually
ceased or wheio it is piesent in very small
quantities Yearsley's cotton purls aio made by
lolling pieces of absoibent wool into small balls
or cylinders, which, when moistened with some
antiseptic mud, should bo introduced undei
illumination by means of a delicate pair of
forceps and placed against the leinams of the
membiane, so as to exert slight pressure upon
the he.wl of the stapes or he-id of the malleus
At fiist they should be worn for a few houis,
tho period being gradually ptolonged until they
are boine with impunity They should, how-
over, bo removed at night and xeplaced the
following morning It is often advisable to
intermit their use foi a few days, and it is
icmarkable that m many cases after such a
period of iest the hearing powei afterwards is
consideiably better than before In cases
wheio they cause maiked nutation tind a le-
crudcscenco of the suppuiative piocess then
use should bo interdicted Tho patient, aftei
having been shown the method of mti educing
and of placing the aitificial drum m situ, rapidly
acquires an astonishing dexteiitv in its manipu-
lation
In a certain niunbci oi cases tho ucatricial
poition of the meinbtana tympani will bo found
to be unduly lax, and as a irsult not only will
audition be interfered with, but the constant
movement of the cicatrix pioves a source oi
annoyance to the patient To relieve this,
incisions into the cicatrix, or tho collodion plan
of tieatment, by means of which tho lax cicatrix
is held in position by a film of collodion, may
be employed
Adhevoni — As tho result of chiomc suppura-
tion of the tympanic rnucosa, adhesions may
form between the remains of the membranu
tympani or a cicatrised membrane and tho inner
wall of the middle car, between the ossicula
themselves or between tho ossicula and the
adjacent tympanic parictes, or between the
foot-plate of the stapes and the margins of the
fenestra ovalis Varying degrees of deafness,
tinnitus, and vertigo may consequently result.
EAR MIDDLE EAR, CHRONIC SUPPURATION AND SEQUELAE
497
In recont canes such adhesions may be broken
down or considerably stretched by moans of the
air douche, Siegle's speculum, or Dolstanche'a
masseur Lucae's proln?, by everting an inter-
mittent presume upon the osmoular chain and
by producing passive movements, is at times
useful, although few patients will tolerate its
continuous employment When practicable,
division of cicatricial bands or excision ot
adherent cicatuces by means of suitable instru-
ments may be tucd Mobilisation of the stapes
or tiephming of the footplate of the stapes has
been said to piorluco gocxl icsults in certain
cases Excision of the malleus and incus or ot
either when emlwdded in scar tissue or when so
adherent to one another 01 to the adjacent walls
of the middle ear as to be practically fum tion-
less, is undoubtedly a icasonablo piocedure and
worthy of tnal
In all such mtratympumc operations strict
antisepsis should be observed
Calcaioous deposits upon the membrane are
frequently iound in post-suppmatn e affections ol
the middle eai Such deposits may occur upon
any part of the membrane* A by no means
unusual appearance consists in the piesence oi
two bcmilunai patches of a white 01 yellowish-
white coloui with sharply defined edges, one in
tiont of and one behind the manubrium mallei
Occasionally the whole memhiana tonsa undei-
gocs calcai rous dcgeneiation
Ifypeio*t<w* — As a lesult of long-continued
suppurative middle eai disease the lumen of the
external auditoiy meatus may become stenoscd
from hyperostotic thickening of its bony walls
The accompanying stenosis m.iy be so gieat as
to sciiousty impede the fiee escape of pus fiom
the middle eai and < onsequently to jeopardise
the life of the patient
Tiedttittnt — Attempts mav bo made to dilate
thu meatus by HUMUS of the mtrodiu tion of
laminaiia tents or cylmdeis of wool soaked in
alcoholic solutions of boracic acid, acetate ot
lead, etc In wc^ere cases, and where evidences
of retention are present, the m.istoid antrum
should be opened and the po^tenoi wall of the
external meatus chiselled awav
Facial jiataJyst^ may lesult either horn a
parcnchymatous neuritis of the f.uial neive
(without interstitial changes) secondary to
disease within the tympanic cavity, 01 may
be induced by a carious condition of the bony
walls of the aqueductus Fallopn If the paia-
lysis is duo to disease within the middle eai
the muscles ot the corresjxmding side of the
face become paialysed, if, however, due to
central disease, the facial muscles upon the
side opposite to the existing ear lesion aie the
ones implicated Occasionally bilateial facial
paralysis is met with In tuberculous disease
of the middle ear facial paialysis is a frequent
and an caily symptom
The indications of facial paialysis arc a paitial
or complete inability to close the eyelids and
a general want of expression (best seen during
Facial movements) upon the affected side oi the
face There is also a marked drawing of the
mouth to the opposite side and an inability to
whistle Occasionally the uvula IB deflected
towards the paralysed side When the stapedms
muscle is paralysed theio may be an me i ease
ot hearing, and subjective noises are at times
(omplamed of Should the paialysis be of a
pen rumen t nature atiophy of the facial muscles
and even ot the iacial bones may take place
Ulceiatim of the cornea is also an occasion il
result
T> mf ment < onsists in dealing with the primary
cause as energetically as possil.lt* To keep up
thu tonus of the facial muscles massage or the
application ot the galvanic current may bo em-
ployed Hypoduimic injections of strychnia or
its internal administration are occasionally use-
ful Iodide of }>otassium, especially in cases
with an undei lying syphilitic basis, may be
given The frequently lepeated application of
blistering fluid o\er the mastoid process is
occasionally beneficial
DISKASKS oh IITK MASTOID PROCESS
Anatomy of Mn^toid fioret* — The shape*,
si/e, and form of the mastoid process \ai}
gieatly in different individuals and at difteient
peiuxls ot lite The external ( on formation of
the process atfords no clue as to its internal
structuie, which may be wholly pneumatic,
diploctic, oi pneumo-diploetjc At bnth the
mastoid antnim is alxmt as large as a pea,
and is lined by mucous membiane continuous
with that of the middle eai The \anous
groups of mastoid cells become developed sub-
sequently aiound the antial ca\ity According
to Cheatle, the name " mastoid antrum " is a
misnomei, the antium being leally a poition
ot the middle eai Hence it should be called
"tympanic antium " (see p 456)
The ant mm itselt is a bean-shaped cavity
Its loot is foimed by the tegmen tympain Its
floor inns do\\m\aids and backwaids into the
mastoid process Antenoily it communicates
\\ith the attico-t\ mpamt ca\ity Its walls are
peitoratod by the minute openings of the
sin rounding mastoid cells
MVSIOID PfcRiosims may ensue either as the
lesult ot the mflammatoiy piocess spieadmg
iiom the middle eai along the fibrous tiabeculae
whuh connect the tympanic mucosa \\ith the
periosteum of the external auditoiy meatns, and
so with th.it cmcriug the* mastoid process, or
f loin an extension along connective-tissue strands
of the hbious sheaths of small blood-vossela
whuh inn between the periosteum covering the
lione and the mucosa lining the mastoid celh
In childieu the picsence of the unossified petro-
mastoid fissuic piob,ibly facilitates the spread
ot a deep-seated inflammatory process to the
32
498
EAR MIDDLE EAR, CHRONIC SUPPURATION AND SEQUELS
suiface Pathogenic organisms are thus leadily
conveyed from deep-beated foci of sepsib to the
periosteum covering the mastoid process
In this connection it is impoitant to beai in
mind the largo si/e of the mastoid emissary vein
in children Cases occasionally occur in which
an abscess outside the skull and over the exit
ot this vein dncctlj it'sults fiom extension fiom
the mtenor Sue h eases may present difficulties
in diagnosis, and their true nature may only
bo icvealed on operation
tir/mjittonitt — The initial symptom, as a iiile,
complained of is pain, at first local, and situated
just behind the attachment of the auricle, but
soon becoming general over the corresponding
side of the head It IH always increased by
pressiuc Redness, swelling, and a'dema of tho
supenm|K>sod tissues soon follow, with the result
that the car gets displaced downwards, foiwaids,
and outwards, and, in cases wheie the oedema
is veiy market!, appears to stand out prominently
from the side oi the head This drooping of
the auricle is specially noticeable when the
patient is examined fiom behind At times
the (udenia becomes so extensive as to extend
forwards ovei the f.ice, producing thumosis ol
the lower eyelid, or spreads upwaids o\ei the
surface of the scalp
Commensurate with the amount of suppina-
tion under the periosteum is the dogiee of pain
and geneial discomfort of the patient, who
exhibits a niaikcd rise of tempeiature, a lapid
pulse, and the ordinal y symptoms of febiile
icaction
Such attacks of penostitis may aboit without
pus formation, but usually an abscess of varying
size forms under the periosteum, and as it in-
creases strips it from the bone ovei considerable
areas The denseness of the superficial tissues
letards spontaneous evacuation, which, howevei,
may take place either behind the eai or thiough
the postero-supenor wall of the exteinal auditory
mcatus
In the early stages of the affection a busk
puigative should bo given, the patient being
kept within doois and in a waim loom Cold
applications, such as iced - cloths, horseshoe-
shaped ice caps, 01 Letter's continuous cold coil,
may be applied behind the ear with advantage
The local abstraction of blood by means of
leeches, or Heurteloup's artificial leech, by
diminishing congestion, may bung about reso-
lution Irritating applications such as aconite,
iodine, etc , should be avoided as only tending
to mask symptoms Where pus has formed,
and even where it has not, but where the tissues
are tense and infiltrated, great relief is afforded
by incision The requisite incision, Wilde's
incision, should be mede parallel to and J inch
behind the attachment of the auricle, and from
above downwards for a distance of from £ inch
to 1 inch. It should be made down to the bone
throughout its entire length It may be necos-
saiy to hgatc the posterior auricular artery,
fiom which haemorrhage is usually free, but
A fair amount of depletion is to be encouraged
as tending to dimmish local congestion Where
pointing takes place towaids the external audi-
tory mcatus its postcio-superior wall should be
fieely incised The lips of the incision thus
made should be kept apart foi a few days by
means of au antiseptic diessmg, after which
they may be brought togethei, provided no
othei symptoms contra-mdicate clcsuie In
cases where mastoid pciiostitis is secondary to
acute inflammation within the mastoid cells,
and wheie symptoms do not subside within
forty-eight hours, an opening into the bone
should be made Again, when mastoid peii-
ostitis is complicated with a fistula leading to
canons bone \\ithm the piocess, suitable tieat-
ment must be follow ed out, c if enlai gmg the
fistula and sci aping away all a>ai!able disease,
01 the perfoimance of a ladical mastoid opeia-
tiou
The effect upon the inflammaton piocess
within the middle ear aftei tieely musing the
mhltiated tissues o\ei the mastoid pint CM* is
icmaik.ible Suppmation, whi< h had picunusly
been abundant, lapully subsides, with, as a rule,
eaily ticatiisation of the existing perfoiation
SUITUKA'J I v B EN LM WASTOI i>i i is — Pathogenic
infc( lion ot the inuoosa lining the mastoid cells
exists piohahly to a gi cater or less dcgice in all
cases ot acute suppmativc inflammation of the
middle cai It is only, howevei, when le tent ion
ot the iiiflammatoiy pi oduets within the mastoid
antium 01 mastoid cells takes place that uigent
symptoms aiise CoiiHideung the narrowness of
the itei d<f untinm, it is lemaikahle IKW seldom
such retention does take place in acute cases
When, howevei, the lining inembiane of the walls
of the itei bei ome so congested and ojdcmatous
as t'> piodute stenosis of the passage, letention
of mllammatoiy pi oduets is ia-vouicd Symp-
toms pointing to such retention aie seveie pain
over the aiea of the mastoid antium ot infected
mastoid cells, increased upon pressuie and upon
pcicussion At times oedema of the superim-
posed soft tissues takes place, but by no means
neecssaiily With mci casing tension within
the mastoid aica the tcmpeiature uses, and
maj lange fiom 9HJ F to 103" K or even more
At the same time othei oidmary febrile symp-
toms aic piesont, e (j rapid pulse, furred tongue,
headache, etc
Upon examination the membrane will in such
cases be seen to be swollen, congested, and with
its landmarks obliterated The perforation may
be seen to pulsate, and when secretion has been
carefully syringed away it will soon be seen to
re-collect, indicating that some reset voir exists
from which a constant overflow is oozing or
flowing away In addition, the posterior-superior
wall near its attachment to the membrane will
be seen to be prolapsed — the dip, — an almost
EAR MIDDLE EAR, CHRONIC SUPPURATION AND SEQUELS
499
pathognomonic sign of m\olveinent of the
mastoid cells
In cases whoie enlargement of the existing
perioration, antiseptic douching, .ind the local
abstraction of blood fail to relieve pain, and
where tho tcmpcratiuc keeps rising 01 lefuscs
to fall, opening and diamagc of the mastoid
cells should be undei taken
Pre/watum of t/if Patent — Ml han in the
immediate neighl»mhood oi UK* eai should ho
shaved, after whi<h the skm should bo washed
\vith soap and watei and nibbed with othti
(so as to get nd ot all fatty paiticles), and then
carefully <aibohsed The- head should then K
wiappcd in a caibolu, towel, which should be
woi n for some houis picvious to opoiation
Jfrt/iorlofOjHtiitioH (Stkwait t\ OfHintion) —
When the patient is fully under the influence
ot an anaesthetic an incision should be mad<
(Wilde's incision) paiallel to and a quartei of an
inch behind the attadnnont of tho umclc horn
the linca tempoiahs to the in, is told ape\, and !
down to the bone thioughout its entne length
All bleeding points should be ligatod at oiue,
aftei which, with a i.ispatoiy, the peiiostenm
is laised f mm the hone as fat foiwaids .is the
posterior boidoi of the bony meatus The
tissues ate now held toiwaids by means of ,i
broad icti actor, and the smface of the mastoid
piocess is thus cleaily e\j>osed to view
The obje< t is to open up the cavity of tho
mastoid an tn mi ,ind the adjoining tuastoid cells ,
in othei woids, aitei haung tapped the antium,
to follow up any path ot pithogomc infection
which may be disunoicd
To map out the topogi aphu al relations ot
the mastftid antium one of two methods may
t onvemently be employed —
(1) An imagmaiy lino is diawn paiallel to
and a qu.utoi (/f in inch behind the postenoi
bolder of the bony meatus, and anothci paiallel
to its supciior boidei At the point ot mtei
section of those lines opening of tho bone may
be commenced, the general direction of the axis
oi the pioposed opening being downwaids and
forwards paiallel to the postenoi wall oi the
external auditory meatus
(*2) Tit* tivpta-ATttital Tnanyle —Macro on
advises opening the antrum in the supra-meatal
triangle, which is the space formed by the pos-
tonor root of the zygomatic process above, the
postoro-supciioi inaigm of the bony meatus in
front, and a pcipendicular lino diawn through
the postenoi edge oi the meatus and joining
the lines previously mentioned
The depth of the antrum from tho surface
varies greatly, not only m different skulls, but
also at different ages and at different stages of
the disease It may be taken, however, as a
good practical rule that no exploratory opening
should be made to a depth of more* than three-
quarters of an inch for fear of wounding the
external semicircular canal or the facial nerve
Nowadays eithei tho gouge or the bur duven
by a dental engine or an electro-motor is used
to lay bare the antrum and adjoining cells
Macewen, the great advocate of the bin, says
that by its use safety is ensured, janmg of tho
intracramal contents is avoided, and a pei fectly
smooth sin face is secuicd in winch the orifices
of an> fistulous tracts are readily detectable
With tho gouge woikod eithei by the hand
01 by means of a mallet, layer after layer of
bone is removed, a good MCW of the operation
hold being thus always obtainable
Whichever instrument is used good illumina-
tion of the field is absolutely requisite, and mav
be obtained by icflected light irom a limelight
ippaiatus 01 an electric lamp
It is important to remember that the middle
fohba m.iy bo found unduly low, that the knee
of the lateral sinus may corne nearer to tho
postcnor \\.ill of the external auditory meatus
than is usual, and th.it its position may be very
supcihcidl, in oi dei to emphasise the necessity
ot caio m all manipulations
During tho icmoval of the xanous layeis of
bone fioquent lecourso should be made to ox-
aunnition with a pointed pi oho to ascertain the
extent and tho si/e oi the \aiious cells w huh
may lie opened When once the antium has
been tapped its extent and depth may icadily
be gauged bv means of the antrum hook. All
oveihangmg bone must now be gouged or buried
away, .ill infected cells opened up, and a cone-
shaped cavity foimed, with its base supeificial
In cases oi .icutoanti.il cmpyema it is neither
necessaiv 1101 achisahlcto open up the cavity
of the middle eai Tho cone-shaped cavity
piodwod as above descubed should IK» eaiefully
fined (all synngiug being avoided), dusted with
some antiseptic powdei, and packed loosely
with an antiseptic gau/e Healing by means of
granulation tissue aft imo should l>e encouraged,
and in uncomplicated < ases takes place within
a few weeks
CllltOMt SU1TUI<V11\K EXDOMAhTOlDlTUS —
Suppiuatno disease arising within the middle
eai is prone to extend^ to the mucosa lining
the antium mastoideuui and the adjacent mas-
toid i oils Owing to the complicated arrange-
ment of these cells the free egress of pus
is frequently inteifeied with and chiomcity is
iavouicd Pathogenic oigamsms also find a
suitable habitat within those recesses, and con-
sequently tlnivo luxuriantly The mucosa of
tho part, semng as it does tho function of a
poiiostoal lining, tends to undeigo ulcerative
changes The underlying bone thus becomes
denuded and loses its \itahty Caries, necrosis,
01 eai 10 necrosis consequently frequently result
In this way laige portion* of tho temporal bono
may exfoliate The most frequent sites foi such
cario -necrotic processes are the outer wall of
the mastoid, tho postenoi wall of tho external
osseous meatus, tho bony groove for the Bigmoid
500
EAR MIDDLE EAR, CHRONIC SUPPURATION AND SEQUELAE
sinus, the roof of the middle oar, the toof of the
mastoid antrum, the pare piomontona, and the
bony capsule of the facial nerve. The osseous
partitions separating the various raastoid cells
from one another become gradually disintegrated,
with the result that cavities of \arymg size
form within the mastoid process full of purulent
debris, granulation tissue, and cholesteatomatous
material. In other cases, however, instead of a
rarefying osteitis taking place, a condensing
osteitis may ensue, with the icsailt that the
individual mastoid cells become obliteiated, «i
mass of dense ivory-like bone being fanned
The subjective symptoms of the pi essence oi
caues or necrosis within the mastoid process RIO
comparatively ummpoitant Occasionally pain
may bo complained of, especially when an aiute
pithogenic infection is grafted upon an already
existing chronic protest, or where as the result
of osseous erosion some mtracramal complication
is set up As a result of the pieseuce of a
sequestrum, or as the result of the presence ot
canes of tho labyrinthine walls, tinnitus and
vertigo may be complained of
The objective appearances aio, ho\\evei, \erj
important, and consist in the piescnco ot (1) a
more 01 less copious dischaige, usually \ciy
foetid, occasionally blood-stained, and fieqnontly
containing small spicules of dismtegiated bone
(2) granulation-tissue masses, which when ic-
moved are pione to recur f (3) onlaigcd pen-
auricular lymphatic glands , and (4) the iiequent
piescnce of facial paialysis
A diagnosis of deep-seated canes 01 necrosis
may be made by ociilai inspection or by palpa-
tion with a suitable probe Occasionally a
positive diagnosis is impossible, but the pie-
sumption is in favoui of the existence of bone
disease when in a chiouic case continuous anti-
septic cleansing of the part fails to ariest dis-
charge and foctoi
By means of a piobe canons foci may be felt
The sensation impaited is that of roughness,
combined with a coitam degieo of softness
Where definite sequestra exist they may l>o felt
to bo mobile
Treatment — Thorough cleansing of tho dis-
eased areas is imperative, but it is not by any
means always attainable without iccouise to
operative measuies Whcie the external mcatus
is stenosed owing to disease of its posterior wall,
Avith infiltration of the soft tissues, specially fine
synnges may bo required for irrigation pui poses,
or it may bo necessary to dilate tho canal by
moans of cylinders of wool soaked in acetate ot
lead solution or nibbei tubes of gradually in-
creasing call In e Tufts of exubeiant granula-
tion tissue glowing horn carious foci should be
scraped away so as t<* allow of icmcdial agents
acting upon the underlying disease Sequestra
when sufficiently mobile should be removed by
forceps or scoops The mam indications for
opening the mastoid piocens when affected by
chronic inflammatory disease may be summarised
as follows . —
(1) In cases where caries of the tympanic
walls exists
(2) When i centring attacks of mastoiditis are
present, especially if complicated by the presence
of a mastoid fistula
(3) When a mastoid fistula is present loading
down to carious bone
!4) In cases of cholestcatomata
5) In rases of hjpeiostotic stenosis of the
external auditoiy mcatus
(G) In cases of obstinate mastoid neuialgia
(the icmoval of a wedge of bone is usually
sufficient in these cases)
(7) In cases of tubeiculosis of the middle cat
01 mastoid piocess
(8) In cases ot proti acted and ftrtid suppura-
tive inflammation of the middle ear which hroe
lesisted the oidmary methods of local tieatment
This indication bar* led of late to much serious
discussion, 111.1113 eminent anthoiities claiming
that pi oti acted suppuiation pet s<° is not a
sufficient indication lor opeiation in the absence
of in gent symptoms Pi ofcssoi Macew en regards
the opeiation of opening the mastoid as the
safest and the most efficient method of eiadicat-
in» othei \\ ise persistent pin ulent otitis media
(9) In all cases of suspected intitu lamal sup-
puiation the mastoid antrum should be opened
as the hist step in the operation
The methods ot opeiation most frequently in
use aie those designed by Sr hwait/e and Stackc
A combination of the t\\o mentioned known as
the Schwaitze-Stacke operation has been much
111 vogue of late yeais, and has yielded when
piopeily peifoimed \eiy gratifying lesults
PiejxiKttion of Patient — IJy means ot a dose
of aperient medic me the bowels aie well opened
the day piior to the opeiatiou
Pt€2tartttion of 0/wation Fielil — The hail
for seveial inches round the affected mastoid
should be shaved, the skin well washed with
soap and watei, nibbed with tuipentine, and
finally with sulphunc ether The external
auditory meatus should be well syringed with
warm carbolic lotion (1-20) or corrosive sub-
limate solution (1-2000), and packed with lodo-
form or double c>anidc gau/e A pad of lint
soaked m carlwlic lotion (1-40) and covered by
mackintosh should be fixed o>er the head and
kept in 8i tu for some hoius previous to the
opeiation
PK'pnrntwn of Instrument* — All instruments
to be used during the operation should l>e
rendeied aseptic by previous boiling, and should
be left soaking m weak carbolic lotion or in a
solution of foimalm foi a few hours piior to
being used
Tho hands of tho opeiator and his assistants
should be well washed, rubbed with turpentine,
and dipped for a few moments in some warm
antiseptic solution
EAR MIDDLE EAR, CHRONIC SUPPURATION AND SEQUELS
501
Position of Patient — The patient should lie
upon a narrow table of a convenient height, the
head reclining upon a hmi pillow Some good
source of illumination (should be at hand (eg
limelight, electric light, etc ), so that by means
of a forehead mirror the operator may reflect a
strong beam of light into the opening in the
bone Some operators use the mallet and the
gouge to open the autrum and the adjoining
colls, others (Maccwon, JUllance) piefei the
bur worked by a mutable motor, claiming that
by its use theic is no risk of concussion, and
that a cavity \vith poifectly smooth walls is left
behind Whichever operation be selected, and
by whichever set oi instruments the bone be
opened, the object to be attained is to open
up the autium and adjoining mastoid cells, to
follow the couise of any pyogenic lesions which
may present themsehes, opening up if net-d
be the gincm* foi the lateral sinus, inspecting
minutely the loof of the antruin, attic, and
middle eiu, ,ind hnally establishing <ui efficient
and axascular barnei between the middle eai
and the adjoining vulnerable fMits within the
cranium
*VfAwwf.A Oftnafwa — An illusion is made
paiallcl to and [ oi an inch behind the attach-
ment of the amide fiom the hnea tempor.ihs to
the «ipe\ of the mastoid pincess Any bleeding
points aie to be (aught and tied The peri-
osteum is now Mpaiated ftoiu its attachments
along the whole length ot the incision, and is
drawn forwaids until the jwsteuor bony mat<;in
of tho external meitus is In ought fully into
vie\v
The position of the mastoid autium is now to
be defined (*ee p 497) By moans of a gouge
and mallet or by means of a lotatary bin the
bone is cautiously iemo\cd, frequent examina-
tion being made with a tine piobe until the
cavity of the antium has been i cached Its
depth from the surface may \aiy horn J of an
inch to { of an inch Once the cavity of the
antrimi has been reached it* extent can be
icadily gauged by e\ploiation with tin antium
hook The suiiounding bone should now be
freely and lapidly cut away until a (omcal
cavity has been formed with its base uppermost
and its main axis paiallel to the postciun wall
of the auditoiy me.ttus Adjoining mastoid
colls, if diseased, should be opened and then
contents scr.iped out by means ot spoons 01
cuiettes A stream of some antiseptic fluid
should then be dm en thiough the antial cauty,
until it emerges freely fiom the evteinal auditoiy
meatus
It may be, and frequently is, necessary to
enlarge the passage between the antium and the
middle cat, so as to seciuo free drainage This
may be done by means of small tutting foiccps,
spoons, or the rotatory bin Once a perfectly
free communication with the middle ear has
been established, a dunnage tube should be
placed in tho autrum and stitched to the edges
of the original incision, which may now be
sewn up
Subsequent tieatmeut consists m thoiough
irrigation ot the antrum and middle car by
means of various antiseptic solutions When
all suppuration h<is ceased ind the parts opci-
atcnl upon ha\e remained dry foi from ten days
to .1 foitmght the tube may be withdrawn
Owing to the formation of tufts of granulation
tissue, fiee diamage is occasionally impeded.
When such masses foim they should IKJ removed
either uy means of a sharp Hpoon or by the
application of caustic Occasionally the tend-
ency to their foimatiou is so great that it is
advisable to insert a lead plug into the antral
opening instead of a rubber drainage tube, the
weight ami the pressure of the spigot ma tonally
assisting in checking then formation
NlmkC* OjiemhuH, — The incision through tho
soft pails is the same ,IH in tho Sc-hv, urtze opera-
tion, except that it is earned round the auricle
to a point just above thc» tcmporo- maxillary
aiticulation Aftei .ill bleeding points haxe
been seemed the periosteum is raised and diawn
foi ward until the bony maigm of the exteinal
auditory mcatus IB in full view By means ot a
fine raspatoiy the caitilagmous mcatus is now
inised from its attachments, and along with the
auiicle is diawn forwaids on to the cheek In
this way tho tympanic structures are fully
exposed The oiitci wall of the attic is now
lemoxed until an antium hook intioduccd into
the attic and diawn outwards meets with no
obsti in tion All lK>ny prominences should now
be carefully bevelled clown, and diseased ossicles,
gi emulation-tissue tufts, and carious foci succes-
sively dealt with
The auricle and caitilagmous meatus are now
leplaced, a di .image tube nisei ted into the
meatus, and the oiigmal skin incision caiefully
sewn up
The tihinut e-Stmle (ymttttim, a combination
of the two operations just described, is the one
now mo&t usually pcrioimed Attei the usual
skin incision and leti action of the soft parts the
antrum is opened as above detailed and the
postciioi wall of the caitilagmous meatus de-
tached f 10111 its bony bed The budge of bone
which sepai atos the antium from the external
mcatus should now l>e cut away, great care
being taken whilst lemoving its deepest portion
to a\oid injuiing the facial neivc oi the external
semicncular canal The antro-tyinpamc cavity
thus tunned should be carefully cleansed, dis-
eased ossicles, i emu ants of the membrana tym-
pam, gianulation tissue, and carious foci being
success! ully dealt with As in the Stacke opera-
tion the subsequent tie^tmcnt consists in on-
dca\ouimg to secure a permanently diy epithelial
lining in the cavities thus exposed To attain
this end the postenoi wall ot the cartilaginous
meatus is split longitudinally along its centre up
502
EAR MIDDLE EAR, CHRONIC SUPPURATION AND SEQUELS
to the concha, where a crucial incision w made
In this way two quadrilateral flaps are formed,
which are pi eased against the bony walls of the
antro-tympanic cavity, the one up u aids and tlio
other downwards, and kept in titu by packing
introduced per meatum Fiom the edges of
these skin flaps epidormisation comniences, and
spreadH until the whole cavity becomes papcied
with a dry cnticuUi lining The onginal skin
incision ma> bo sown up, 01 (iiuber's plan of
secondary suture may be adopted, by which is
meant the insertion of tluee 01 fom sutuios ,it
the tune of opciation, and their subsequent
tightening some few davs attcn\aids F/vciv
four or hve days ft can packing should be intro-
duced, gicat caie being taken to hll the cavity
completely Any tendency to the formation of
granulation tissue should be comluted by the
application of chromic acid oi nittate of silver
As a rule fiom thiee to four months \\ill
elapse bofoie complete epidernnsation tikes
place
POST-IXH UENKAf, SUPPUHATIVR AlASTOllHTIS --
Suppurative middle car disease ot mfluen/al
origin is chaiacteiisod by the intensity of the
inflammatory process, by a tendency to spiead
to the tissues within the ma&toid, and l)y lapul
destruction of bone Mastoid einpjcmata fol-
lowing att<icks of la guppe aic most hequeiitly
located within the apual (ells, the untral cavitj
and the adjoining cells enjoying .some pccuhai
immunity In such c ascs pain is apical, and is
much aggravated by piessme upon the mnci
and anterioi aspcet of the pio< ess
In the treatment ot smh subcoitu.il abscesses
it is necessary to open the apical cells ireely, to
bcrapo awaj all softened bone and succulent
granulation tissue, and to connect the antial
cavity with this abscess cavity by means ot a
gutter-shaped trough Healing by the foima-
tion of healthy granulation tissue lapidly follow s
BEZOLD'H MASIOIDITIS — In ccitain cases of
suppuiativo endomastoiditis perforation takes
place through the inner surface of the mastoid
process, close to its tip and into the gioote of
tho digastric muscle Pus consequently may
collect under the deep cervical fascia, giving rise
to infiltration of the cellulai tissues of the neck,
with formation of a haul brawny swelling , or it
may pass, guided by processes of the deep cervical
fascia, downwards towards the mediastinum
Treatment — Free ablation of the apical mas-
toid cells is called for in the first place A
counter opening should also be made in the
neck and thorough drainage established Such
cases often run a peculiarly protracted course,
owing to the practical difficulties encountered in
providing efficient surgical drainage
(11IOLESTKATOMA TrhlS COlldltlOll OCC111S 111
cases of old-standing suppurative middle ear
disease, and is geneially held to result fiom an
ingrowth into the tympanic cavity through a
perforated membrane of epithelial cells from the
dermic layer of the external auditory moatus
Virchow, however, regards these epithelial
masses as true neoplasms Such ingrowing
epithelium, mixed with crystals of cholesterme
and inspissated pus, collects in concentucally
ai ranged masses vulhm tho tympanum or mas-
toid antruni, leading frequently to dilatation of
those ca\ ities and at times to perforation of the
sin rounding bonj panetcs Cholesteatomatous
m<isses swarm with organisms, and when stirred
up into activity by some intei current inflam-
matory process may give rise to most urgent
symptoms, e <j pain, rise of tcmperatuie, etc.
As a rule snigical tieatment has to lx» lesorted
to, although occasionally, it the masses are
small and situated fan ly superficially, they may
1)0 washed out by means of an mtiatympanic
syringe 01 dislodged by scoops 01 curettes The
instillation of lectiticd spnits may be used with
the idea of dehydrating the mass, and so of
starving the m companding mi< ro-organisms
Wateiy solutions should be avoided Then
marked tendency to teem, and the inheient
dangei which then piesence gives use to, calls as
a iiile foi huruual treatment Stacke's ladical
mastoid o pel at ion maybe perioimed with advan-
tage Hheinhaidt has suggested, aitei cleuimg
out all diseased mastoid cells and epithelial
masses, the maintenance of apeimancnt mastoid
fistula, so that in tho exent of any iccurience
taking pl.u e cfli< tent lo< il treatment mav at
OIK e be undertaken Tiaiisplautation of flaps of
skin into the cholesteatomatous cavity aftei it
has been freely laid open has also been suggested
TuiiKitcui oi, s DLSE vsfc
Tubcn ulous disease oi the middle eat is hold
by nian^ authoiities to urn a chioiuc course
nb imtto Its piesenco is i hanietensed by a
somewhat sudden onset, without, howevei, am
sthenic symptoms, by a painless perforation ot
themcmbianatympam, and b} an caily involve-
ment of the pel i-auncular lymph glands, and by
the frequent piesence of euily paialysis of the
facial nerve
Examination of the membiane, which presents
a pale, sodden, and ccdematous appeal ance, re-
veals the presence of one or moie perforations
with thick, succulent, and a vascular edges Tho
accompanying dischaigc is usually thin, scim-
puiulent, uii(l frequently veiy foetid Buds of
flabby gzanulation tissue pi ot rude through the
perforation, and are very hequently associated
\\ ith deep-seated caries either of the pars pro-
moutoiia or of home portion of the mautoid
process
In all probability the disease may be primary
within tho middle ear, infection toing conveyed
per fiihatti
In cases of advanced phthisis, the middle ear
occasionally becomes involved, painless perfora-
tion resulting Such n complication has a bad
piognostic indication
EAR. MIDDLE EAR, CHRONIC SUPPURATION AND SEQUELS
503
In such cubes caieful examination of the dis-
charge should bo made for bacilli Should they,
however, not bo found in the discharges from
the middle ear, any accompanying granulation
tissue should be removed and examined Occa-
sionally they may be discovered in thin way.
Failing this, poitions of diseased tissue from the
middle eai may bo removed and inoculated into
guinea-pigs or rabbits If such experiments be
conducted with due precautions to a\oid acci-
dental contamination, and if tuberculous disenso
be set up in the animal so inoculated, the pie
sumption is that the material employe! is
tubeiculous Tubeiculous disease ot the middle
ear is frequently associated with snmlai disease
within the mastoid process
In many siuh cases \\heio the niastoul has
been opened toi the pui poses of treatment, a
pultaccous-looking mass will bo found tillinu up
the < ells, but this mateiial is piattually value-
less for experimental pmpo-.es, consisting as it
does of bioken down tissue, inspissated niiiuleiit
debus, and epithelial cells Vi hen, however, it
has been lemoved b\ means ot a spoon and the
undeiljmg bone exposed, it will be seen where
the disease is nuking pi<n:ress, and imui whence
a se i.iping ot bone should be taken
In my expei iments I have nisei ted a fragment
of tissue obtained as abo\e tlesciibed into a
guinea-pile's hind leg, just about the knee-joint,
all han ha\mg piowously been n»ni(ned bj
singeing with a platinum knite A small pocket
is now made with a steiihscd needle, and the
tissue caielully insetted In a few weeks' tune,
should the tissue inoculated be tubemilous, the
inguinal glands will be found enlntged, and a«»
tune gots on the tuberculous vnus will be found
to have spiead over the animal's bod>, the
glands and viscera being attacked in the follow-
ing oidei, accoidmg to the lesults obtained bv
Proicssoi Dele pine —
Duiniq thr vrrW if'ttt alter inoculation the
lymphatic ganglia upon the same side ot the
body below the diapluagm and the spleen will
be found cnlaiged
Duiim/ the thud wel, the livci, the medias-
tinal, and the bionchial ganglia
Duinif/ thf fotuth wwi, the lungs, the eeivi-
cal and the axillaiy ganglia
After the Join th md some of the Umphatu
ganglia of the opposite side ot the body below
the diapluagm become affected, but this takes
place extremely slowh, and the sublumbai and
popliteal glands escape for a conhiduiable time
Micioscopic sections made fiom these glands,
and stained for bacilli, will frequently be found
to ic veal their presence
In this way a definite diagnosis of the actual
character of the underlying lesion can be made,
and the value of the knowledge thus obtained is
naturally immense, both as regaids prot»nosis
and treatment
The course of such tuberculous lesions is onl)
too often a downward one, despite the most
elaborate and painstaking treatment The
practical difficulties encountered in removing
tuberculous deposits within bone are immense,
and in no region of the body ate these difficulties
greatei than when tubercle attacks the temporal
bone, for icasons which must be obvious to all
The complications whn h ha\e to be feared
are (1) meningitis, (2) tuberculous enteutis,
(3) general maiasmus
The treatment of such cases must bo con-
sidered fiom two points of view, accoidmg as it
is non-opeiative or operative Cases will be met
with, especially m infanta, wheic any operative
intoifei ence will from the first be seen to be
1'opelcss
>>U(h aie the cases when* maiked debility
and emanation aic present, wheic a Ivauced
laual paialysis and masses of enlaiged glands
ha\e been eailv symptoms, and where the dis-
( haige is Abundant, fojtid, and frequently blood-
stained In such casrs palliative measures, anti-
I septw tieatment, and, if possible, residence at
the seaside, are indicated, but I am bound to
I say that in the majoiity of such patients whoso
I cases I have followed an eaily death has been
the usual histoiy The prognosis in such cases
I bchc\e to be essentially bad
In other cases, howexci, where the present
! condition ot the patient is good (.md often
I enough it is so), and when- the tubeiculous
lesion may be legaided as pumary and local,
much can be done by suitable opeiatne mter-
teience It is almost superfluous to sa) that
the hist and the mam essential is to pi ovule
liet; dunnage This implies opening <md cleans-
l ing the mastonl cells, and it is a remarkable fact
j how often in siuh cases, without any external
| and objective sign 01 indication, the mastoid
j coitex \\ill be found extensively perforated, and
1 ,i pultaeeous mass immediately exposed to view
, 1'iidei good illumination a \eiy careful toilet of
the pait should be effected, and this can gcnei-
1 ally best be done by means of u sharp spoon
I All softened and canons bone must be scraped
j aw a), and as smooth a caMly left as possible,
e\en it this necessitates hi} ing bare the dura and
walls ot the lateial sinus The cavity thus ob-
tained should be allowed to granulate from the
| bottom, and care must be taken to stimulate
| any sluggish aiea by means of applications of
i chloride ot /me, mtiate of silver, etc Fre-
quently moie than one sciapmg is necessary as
tiesh foci ot disease appeal In one particular
case which came nuclei my treatment some
vais ago, and where the cause v\as pioved to
have been feeding vv ith milk from a tuberculous
eow, five separate opeiations had to be under-
taken before the moibu^piocess was eradicated,
which, however, it finally was, and the child has
now grown up a healthy and sturdy boy. In
very many of the cases the middle ear has been
so extensively destroyed that its function as an
504 EAR: MIDDLE EAR, CHRONIC SUPPURATION AND SEQUELJS
organ of sense may be disregarded. Under buch
circumstances ltd contents should be freely cur-
etted, and middle ear, antrum, and mastoid cells
thrown into one cavity, and allowed to become
obliterated by means of healthy granulation
tissue. Where, however, a fair degree of hear-
ing is present, efforts should bo mode to preserve
the function of the organ so far as is possible
An important point arises in connection with
the treatment of the accompanying large glands
Some of the glands may be enlarged purely as
the result of septic absorption, and it the morbid
cause be removed this enlargement \\ill gradu-
ally subside, especially it aided by suitable
treatment But many of the glands are of a
tuberculous natuie, and are prone to undergo
caseous degeneration, \\lulc at the same time
they are a source of possible systemic raiec-
tion Hence I hold that after the mastoid area
and the cavity of the middle ear have been
attended to, and as boon as the condition of the
patient admits of it, another operation should be
undertaken with the object of removing these
enlarged and tuberculous structures
The facial paralysis which so often accompanies
tuberculous disease of the middle eai is unfoi-
tunately usually permanent Something may,
however, be done by facial massage and the in-
ternal admmistiation of stiychnm to assist in
maintaining the ton us of the facial muscles
General treatment, such .is the exhibition of
cod-liver oil, iodide of non, syrup of iodine, etc ,
is useful, as also is change of air arid liberal diet
The general conclusions fiom a study of these
cases may bo summarised an follows —
1 That pnmai y tuberculous disease in and
around the middle ear is of fairly hequcnt oc-
currence, and that it most usually attacks the
child ten of the poor, especially the poor ot our
larger cities
2 That a generalised tuberculous infection
may arise from a pumary focus \vithin or aioimd
the middle ear
3 That the prognosis m such cases is not
very favouiable, at least 40 to 50 pur cent oi
the cases succumbing even after opct alive treat-
ment has taeii undertaken
4 That in many of the cases, operative mtei-
feronce is t ontra-mdicated, owing to the extent
of the existing disease and the asthcnic condition
of the patients
5 That when operative interference is feasible,
the main object should be to sciape away all
available foci of disease and to provide efficient
drainage
6 That the best and the most reliable means of
establishing the tuberculous nature of the disease
is by means of propeily conducted inoculation
experiments. c
INTKACUANIAL COMPLICATIONS FOLLOWING
CUKONIC SUI'I'URATIVE Ol'lTlS MEDIA
Extension of a pathogenic infection from the
cavity of the middle ear or mastoid antrum to
the interior of the cranium takes place either as
the result of carious destruction of the surround-
ing bony parietes, or as the result of infection
spreading along the minute emissary veins or
lymphatic channels which connect the mucosa
of the middle ear with the memngcs and in tenor
ot the brain, or directly through various hssmes
or defects in the osseous framework oi the part •
The most usual sites of carious destruction
of the bony parietes of the middle car are —
(1) The teginen tympani and loof of the
mastoid antnun
(2) The posterior wall of the mastoid antrum
(3) The inner wall of the middle car — pars
piomoutoria
(4) The Iwny walls of the oqueductus Fallopn
In certain cases extension to the intenoi of
the cranium takes place \uthoutanydestiuction
of surrounding bone, the pathogenic infection
being convened diiettly fiom the septic focus
within the middle eai by means of veuouH or
lymphatu channels, a septic thrombosis of these
vessels taking place, \\lneh m turn m followed
by abscess formation
The mtracramal lesions most usually met
with secondaiy to chiomc suppi native middle
ear disease aie (1) evtiadiiral abscess, (2)
pachyiiiciungitis , (3) suppurative pia-araclmitis ,
(4) tempoio-sphenoidal abscess , (5) ( eiebellai
abscess, (6) thiombosis of the lateial sinus,
(7) suppmatne encephalitis
KxritA-DuHAL AHSCESS — The most usual sites
for evtra-duial abscesses are (1) over the teg-
men tympani , (2) over the tegmen antu , and
(3) in the ncighhouihood ot the groo\e foi the
sigruoid Minus Their size vanes immensely,
being sometimes very minute, at othei times
being so laige as to contain seveial ounces of
pus The underlying hone is frequently dis-
colouied and unions, ami may in exceptional
cases become pcitoiated, so that pus collects
under the pen< ranium, constituting \vhat is
known an " the shut-button abscess "
The dura mater limiting the abscess cavity
is frequently thickened and studded with tufts
of exubciant gianulation tissue At times it is
perforated, the abscess cavity communicating
either with the aiachnoid cavity or directly with
an intiaciamal collection of pus
The symptoms of an oxtra-dural abscess aio
pain, at mst local, but frequently becoming
geneiahsed, rise of temperature, lapid pulse,
nausea, and \onnting, and in advanced cases
symptoms of cerebral compression Should the
abscess cavity be situated immediately o\ei or
m the neighbomhood of the motor area, symp-
toms of paresis or paralysis of various muscles
or groups of muscles may be noted
Kxtra-dural abscesses in the neighbourhood of
the groove for the sigmoid sinus are frequently
associated with thiombosis of the sinus or with
cerebollar abscess
EAR • MIDDLE EAR, CHRONIC SUPPURATION AND SEQUEL E 505
PACHYMKNINUITIH is frequently associated with
oxtra-diiral abscess and with suppmative pia-
arachmtis (lepto-memngitis) In many cases it
is the result of an effoit of nature to eiect a
Iwrrier between a suppurating focus within the
middle ear and the adjacent brain tissue, so as
to prevent the invasion of nncio-organisms In
such cases the dura becomes thickened and granu-
lar by the deposit of fiesh fibrous tissue within
its layers, and adhering to the sin founding bone
by plastic exudation Wheie the uivleilyini;
Iwno is carious and peifoiated, tufts of granula-
tion tissue may protiude into the cavities of the |
middle ear and mastoid antitim, and may be .it '
fust sight mistaken for auial polypi
SUITUIIATIVE PiA-AuACHNi'iis (lepto-menin-
gitis) is at times ^ely extensue, spreading o\er
the whole base of the brain, and .it times o\er a
considerable portion of the coitex It is fre-
quently a complication of mtiacianial abscess 01
of sinus thrombosis Occasionally terebial or
ceiebellar .ibscesses mpture into the aiachnoul
cavity, with the result that dilluse utid Molent
aiachmtis is r.ipidly set up
tii/mptom* of /'«(/<//- ami fajttrt-J/enmt/ttn-
Thc symptom fust complained of is pain, whuh,
from bcintr local, rapidly becomes diffuse and
intense The tempeiatuie is clrvatisd, and in
uncomplicated c.ises icmams so Wheie, how-
ever, meningitis isasso< lated with abscess it may
lie sulmoimal The pulse is tapul and high
Vomiting is usually picsent, and may be quite
independent of the taking oi food ( 'onstipation
is also a piominent s\mptom, .uid is fie(|uently
associated with i maikedh letiacted abdomen
In basal meningitis pain at the back ot the head
and neck and rett action ot the he.ul are iie-
qnently piesent Photophobia, strabismus, «md
optic neuutis, although by no means constant
symptoms, are CM ( asionally piesent Ceiebial
symptoms aie mainly ot the initative type,
consisting of me leased excitability, lestlessness,
convulsions, and geneial m itabiht}
Meningeal symptoms aie, howe\ei, frequently
masked by other mtiaciani.il lesions, stub as
abscess or thiombosis, rcndeiing an exact dia-
gnosis piactually impossible
ParaeentcMs of the spinal thcca occasionally
affoids useful infoimation Thus, in cases ot
cerebral abscess the quantity of albumen in the
escaping ceiebro-spmal fluid is slightly increased ,
in meningitis it is maikudly so, so much so th.it
more than 1 per cent of albumen indicates the
presence of meningitis Absence ot polynu< Ic.u
leucocytes would indicate absence of any inflam-
matory condition of the Icpto-mcnmgcs
TFMPouo-Si'iiKNoiDAL ABSCESS — The majonty
of temporo-sphenoidal abscesses occui in young
subjects and in those under thirty years oi age
They occur with an almost equal frequency
upon the right and upon the left side , they aie
more frequently found in males than in females,
the proportion being neaily 2 to 1 As a rule
they follow ch ionic suppurative lesions in and
around the middle ear, although they are met
with secondary to acute dise.ise Occasionally
an abscess may occur upon the side opposite to
the existing ear lesion They may he encapsuled
within the suhstaru e of tho tenijwro-spheiioidal
lobe, a /one of healthy bra'ii tissue intervening
between the abscess cautyand the eai lesion,
or they may be connected w ith the cavity of the
middle eai by means of a fistulous tract through
a peitoiated tegmen tympam The contents
of the abwess ca\ity consist of thick purulent
mattei, often gieemsh in uolom, and extremely
tcctid In i event cases there may l>e a distinct
limiting membrane, in dnoinc cases a thick
p^ogenu capsule The sun ounding brain sub-
stances may be inflamed, softened, and occasion-
ally neciotic
Aii .ibscess may he doi iii.mt w ithin the sub-
sume ot the brain foi many yeais, until an
mjuiv or some mciease of pathogenic infec-
tion due to exposuie, cold, ett , may light up
the alieady existing lesion with disastrous
results In a tew cases they spontaneously
diy up, 01 become (onveitcd into a cietaceous
— One oi the eai best and most
important of the svmptoms of temporo-sphen-
oidal abscess is pain This is frequently com-
plained of dnectly o\er the site ot the abscess
<.mty, but may and does OKUI in any pait of
the head, hence its actual site has no pathogno-
momc impoitance It is usually of a dull,
aching ch.nacter, increased by pressure, and
especially by peicussion After a ^aIymg
duration, diowsmess and stupor aie mani-
fested, the patient exhibiting all the symptoms
of slugirish cerebiation Vomiting of the ceiebral
type is an eaily find important symptom, and
may coi itm i le i 01 da \ s The tempei ati ire, w Inch
111 the initial stages of abscess foimation is
elevated, soon falls as piessme s>mntoms m-
cicase, until it niaj become one 01 two degrees
below normal Should the abscess buist into
the c.uity oi the pia-aiachnoid 01 into one ot
the tciittules, a lapid iihe lesults Tho pulse,
which dining the eaily stage of the disease may
be rapid tends to fall just as the tcmperatuie
does, until its beats may numbei only'thnty 01
toity per minute The lespnatioii wave tends
also to become reduced jmii JKIWI with a fall in
tempeiatuie and pulse late
Paresis 01 paialysis of ceitam muscles or
gioups ot muscles upon the opposite side of the
body is also ticquentlv noted, and is duo to
piessme upon the motoi aieas, 01 upon the
motor fibres i mining thtough the inteinal cap-
sule Paialysis of the third nerve is compara-
tively frequent, and give^nse to such symptoms
as ptosis, dilatation of the pupil, loss of accom-
modation, and a downward and outward move-
ment of the eyeball Paralysis of the seventh
ncive, affecting the facial mubclos of the opposite
506
KAR . MIDDLE EAR, CHRONIC SUPPURATION AND SEQUELS
side, is at times noted, and is due to cortical
involvement.
When the abscess cavity is in the upper and
posterior part of the tempoio-sphenoidal lobe,
sensory aphasia is piesent, when towards its
apex and upon the left side motor aphasia may
be noted, due to piessiue npou Bro&t's convolu-
tion Optic neuritis may or may not bo piesent
As intracramal picssuio increases, symptoms
of coma ensue If, howetoi, luptuio ot the
abscess taken place into the vontiiclo or into tho
arachnoid caMty, symptoms ot cxtiomc excita-
tion arise, accompanied by lestlossness, comul-
sivc seizures, and tapid elevation of tcmpoiatute
CEREBELLAR ABSCESS —About oiie-thnd ot all
lecorded mtracranial abscesses, seconduiy to
chiomc suppurati\e otitis media, oiom \\ithin
tho cerebellum Then most usual situation is
ton aids the an tenor e\tiomit\ of one 01 othoi
lateial lobe , they aie ficqiicnth associated with
septic thrombosis of tho lator.il sinus, 01 with
an e\tra-dural abscess m the posterior c orehr.il
fosua
The symptoms which an abscess in the ceie-
bellum gi\es rise to are very much the san o as
those pi od need by an abscess in the ccrolniini
Pain, which in temporo-sphonoidal abscesses ma\
occur in almost any patt of the head, as befote
descnbed in ceiobellar abscesses, is moie fio-
qucntly occipital Othei symptoms, such as
pulse late, tompciatuio, lospnation rato, etc,
are gen fined by the same uonei.il principles as
hold in tcmpoio-sphenoidal abscesses Uidch-
ness is, howwci, an indication of some impoit
anew, and in ccitam ceiebcllar abscesses is \oiy
matkcd, and its chaiactei may prove ot localism"
value Optic neuritis is fiequent, and complete
blindness may be noted Constant A.iwiimu: has
also been noted
Retraction ot the head, intolerance ot light,
and lapid emaciation aie nnpoitant indications
In cciebellai abscess sudden death may oc"m
from rupture into the fourth MMitiicle, 01 from
prossme upon, or anloina aiound, the ivspuatoiv
centre
THROMBOSIS or THE LAIEUAI, SINUS occurs, as
a rule, from carious destruction of the bony walls
around the sigmoid sinus In most cases, as a
result of perforation of the postenoi bonv wall
of tho mastoid antrum, an e\tia-dural abscess
foims, followed by a phlebitis ot its walls This
phlebitis produces a certain degiec of \enous
stasis, which in turn is followed by the foima-
tion of a thiomhus Tho thrombus, lying as it
does in intimate relation with a septic focus,
rapidly becomes septic and disintegrates, minute
paiticles becoming detached and earned by the
blood stream to distant organs, e t; the luntrs,
the plcuiw, the kidneys, 01 the largei joints,
there to sot up embolic absc esses , OT a general
septic intoxication may be induced, followed by
septicaemia or pj o-septiucima
In a ceitam numbei of casc*s thrombosis may
result without any Ixme lesion existing, the
pathogenic infection being conveyed directly
from the septic focus within the middle ear or
mastoid colls to the lateial sinus, by way of
small cmissaiy veins connecting the mucosa of
the one w ith the fibrous sheaths of the other
A thrombus which has once formed may,
undei ceitam ciicumstancos, become organised,
its oigamsation being followed by tho formation
nf .1 mass of tibious tissue with obliteration of
tho sinus
AVymjito/ns — Tho symptoms which septic
thiombosis of the sigmonl sinus produces rite
mainly those incident to the septic intoxication
\\hich lesults, with, in addition, symptoms
icteiable to tho paituulai oigans in which
motastatic deposits mav ha\o taken place
Uigois aio consequently eail} and impoitant
indications, these ngois ma\ occiu frequently
dui ing tho diiv, the tempciatiiio \ar\mg fioni
103 or 10 4" to normal 01 subnoimal within a
feu houis The pulse rate shows coiicsponcling
variations Pain o\ei the mastoid region in the
neighbouihood of the sinus is ficquoutly i»m-
plamod of, and is usually nit leased by pressmo
and peicussicm Ovloma of tho soft tissues o\ei
tho mastoid mav «ilso CM cm, .ind i*. duc« to block-
ing of the omissaij mastoid \om
As tho phlcbitic process advances, pain is
complained of alon^ the couise of the mtoinal
jugulai \eiu, which iua\ become so thick and
nmltr.itcMl .is to feel like a haid toul The
glands in the immediate, nomhhomhood of tho
A em also become swollen and tendoi
(vonoial H\ mptoms, such as vomiting, diairha-u,
piofuso poispii.itiou, and exhaustion, aio usually
present «>
When omboli become detached and ai rested
within tho substance oi tho lungs septic pneu-
monia losults, hoquontly followed by pulmonary
abscess, and o\on by ganuioiio of the pail If
tho pleura becomes attected difluso septic plemisy
may ensue
The throml>otic process may also sprc<id to
other intiacraiual sinuses, <> <f tho c.ivernous,
| the longitudinal, the petiosal, etc In exccp-
I tional cases a general thrombosis of all the
venous sinuses within the cianium may lesult
As the losult of septic absoiption, a condition
of p}o-soptic<umia may be set up, characterised
bv se\eie febrile symptoms, frequent rigors, and
marked prostiatiou, and by the de\elopment of
septic abscesses, especially in and around the
laigci joints
TREATMENT OF THE VARIOUS INIRACRANIAL COM-
PLICATIONS OF ClIHOVIC SUPPUHATNK MlDDLE
EAR DISEASE
(Koi the method of preparing the patient for
operation, and for other details of opera-
tion, see vol i p 503)
Kiiia-J)u.ral Abws* — In the treatment of
cxtra-dural abscesses surgical inter feiencc should
EAR MIDDLE EAR, CHRONIC SUPPURATION AND SEQUKLA*
507
bo mortal to without delay A disc of bono
should bo removed over tho site of the abscess
and free vent given to all pent-up puss The
abscess cavity may or may not bo washed
out, according to circumstances, but in any
caso ample piovision should be nude foi hee
drainage
Tufts of granulation tissue springing from the
inflamed duia should lx) scraped away with a
hharp spoon
In cases wheio an extia-duial abscess i^ su«-
pccted, but whcio its exact situation is a inatUt
of conjecture, discs of bone should l>e lemoxcd
over the most usual sites ioi its fonnation, vi/
over tho tegmon timpani and ONOI the groo^e
for the sigmoid Minus
I'm hy- and Lejitft-JfenttH/itib Wheie a difluso
suppuiative in 11, inn nation of the covering ot the
biiiin has taken place little or nothing is to bo
expected from tieatment Puigation, doplotion
by means of leeches, ue-bags to the he.wl, .ind
tieatmunt of a suppoi ting nature .110 .ill indicated
and should bo tnorl
A bactciiologK.il examination of the purulent
contents of the middle eai should bo made , and
should the pudomnnnt organism piesent be a
stieptococcus .1 fan inteienco is th.it tho mon-
ingoal inflammation is of stioptococcal o»igm
Undoi such cm mastanccs subcutaneous injec-
tions of .mti-stioptococcic soium may bo tiiod
Wheie meningitis ir%, howovei, local, oaily
opoiativo inteitoience, e tt romoMiig tho bony
hamcwoik aiound the infected aica, cleansing
the pints thoioughly with .intisoptic lotions,
and pio\i(lmg fioe diamago, may bung about an
attest ot the milarnmatoiy piotc'sh
Temjiufo-fytlHnwlal J/>srcs<5 — Should a dia-
gnosis of tcmpcno-sphcnoidal abscess bo made
in any given case, icnunal of a disc oi bone and
cxploiation of tho abscess caMty should bo
unrlci taken without delay \ftoi icflection <f
tho soft paits (<«( \ol i p ">20) tho tiophme pin
should bo made to ontci tho squamous portion
of the temporal bono 1 j inch behind and abo\o
tho c outre ot the cxtuinal auditory moatus
Cotteiill trephines \ inch behind and 1 inch
above tho con tic of the oxtemal auditoi^ ineatus
After removal ot the disc of fame and uu ision of
tho duia (\vhich, if an abscess bo piusent, will
bulge into the opening) a pus searcher (Hoisley),
the blade of a fine knife, or a gioqyed directoi
should bo thiust into the substance of the brain
in various dnections It pus be picsent it will
x\ell up along the gioo\o of tho directoi Bv
means of a fine pan of sinus forceps inti (xlucod
along the directoi and carefully opened so as to
dilate tho tract, the contents ot tho abscess
cavity may bo evacuated A diamage tube of
rubbei or decalcified < hicken bono is now to bo
introduced and tho abscess civity caiefully
washed out \vith warm boracic 01 caibolic (1-40)
lotion The oiigmal skin fl.ip is now to be
brought down (an opening being made ioi tho
drainage tube) and the wound sewn up The
usual diessmgs are then to bo applied
In certain cases a counter-opening through
the tegmen antri or tegmen tyinpam is highly
desnable, pioviding as it does more efficient
drainage and a teacher means of cleansing the
abscess cavity
CeteMlrn Abitew — In operating for cercbellat
abscess, after reflection oi the soft paits (w<
\ol i p r>20), the pin ot the tiephine should bo
mtrodiicod into the substance of the occipital
bono }\ inch tahitid the contie of the exteinal
meatus (Hold's base line) ami \ inch below it
A disc of bone haMiig boon remoxed, the
coiobellum should bo oxploicd, just as has been
pi »Moush det ulud in connoc tion w ith temporo-
sphenoid.il .iliscosses, and the after -treatment
< mid in ted upon the same lines Once tho abscess
c uity h IH fa>en opened and diamed, digital ex-
ploraiion is nt gioat \alue, as occasionally a
scfond.iry .ibsci'ss m close pioxnmty to the
hist may bo piesent, .mil its existence w more
ic.idih made out bv moans oi tho tmgoi than
b\ an^ othoi method
The dithdiltios ot acdiiatc-l} difteiontiatmg
between a teinj)oio-sphenoidal and a ceiobcllar
.ibscess aio so gieat that Penv Dean h.is
suggested a tiephine opening which will expose
both the postenoi pait oi the1 tempoio-sphenoidal
lobe and the antonoi part ol the eerobellur lobe,
whilst at the same time dflording ready access
to the leuitMi of the sigmoid sinus The pin ot
the tiephine is mtiodiued into tho bone 1 nuh
behind and { inch afanv tho centre of the
exteinal meatus and a disc ol bone removed
Special (aio must bo taken to a\oid wounding
the lateial sinus, whuh lies immediately undei
the disc of bono w hu h is being leimned {Should
an abscess c«iMt\ not bo found in the temporo-
sphcnoidal lobe, it is easy to exploic tho antcrioi
pait of the ceiebellum thiontrh the same tiephine
opening
Ltthtnf »S'mws Thtoffllw* — Attoi having
ojMMicd up and cleansed the mastoul antrum and
tho adjiU out mastoid ( ells the knee ot the lateial
sinus should bo ( aietull} exposed b} remox ing the
bone in its immediate neighbourhood Usually
pus in gieatci or less quantity will be found
suiioundmg the sinus Aftei cleansing the
pait a hypodermic needle, should bo thrust into
the centic of the sinus If no blood be drawn
the piesumption is that tho sinus is thrombosed
(the point ot the needle w ill often bo found to have
a very fa'tid smell aftei sue h a puncture) Should
the sin us bo found thrombosed the internal jugular
^elu should be exposed in the neck by an incision
along the antei ioi bordei ot the sterno-mastoid
muscle, tied, and divided The lateial sinus,
after having been cxpoyd Ioi about an inch
towards its occipital end, is now slit up and its
thiombosed and purulent contents freely sciaped
away until free litemoirhage takes place It is
then to be puked in tho dnection of the toicular
508
EAR- MIDDLE EAR, CHRONIC SUPPURATION AND 8EQUKUB
with strips of lodoform gauze. Its pioximal
end should also be sciaped and a btreaiu of warm
carbolic lotion (1-40) syringed along its course
until it flows freely through the divided end of
the jugular vein in the neck Antiseptic dress-
ings are then to be applied in the usual v\ay
The packing within the sinus should be allowed
to remain in mtu for five or MX days, and then
should bo Cfiiefully removed If necessary the
sinus may be repacked
Se/tttc Encephalitis --As has already been
mentioned, the brain tissue in the neighbour-
hood of the suppurating focus may itseli
become inflamed, as is evidenced by wdematous
swelling, softening, diffuse Hiippiuation, and
increase of intiacrauial tension
Treatment consists in eradicating wheie
possible the primary cause, in treating the
secondary focus of suppuiation within the
cranium, m antiseptically cleansing the sup-
puiAtmg cerebral Hintace, and in providing
free drainage
Middle Ear
Disease.
Chronic Non - Suppurative
HYPBUTRormc CAIAIIRII
(a) Chromi JSuitnrAian Ctttotth
(?>) Cktomc Cntarth in Jfntfth Em
Ttact
1 tit a ye of E/iyott/ement
2 titftf/ev of Piolifftatwn <irid
( Ion tra ctton
3 Ctratncial or PwJ-Cntnnhtil
8t<if/e
(t ) Opet (ttive M< « s/m s
A TROPHIC CA-IARRH
CHANGES PRODUCED in VAKIAIIONS IN
PRESSURE
CHANGES PRODUCED in DFMCIENT BMMW-
SUPPIA
50s
508
."509
510
510
51 2
51 8
516
516
UNDER this title ai c desciibed all cases of
deafness duo to middle ear disease, in which the
mcmbrana tympuni is intact
Although gieat ad Nances ha\c of late years
been made in sep.ii.itmg the different ioims, we
are as yet unable, in many instances, to diaw
haid and fast lines between them, thus lendci-
mg description extiemely difficult and often
bewildering The thief difficulty oxpcuciuod
m studying thorn is, that the opportunity tor
pathologic.il examination, in then eaily stages
especially, is larcly obtained
In tuloptmg the following elassilic ation it
must be undei stood that one form often appeals
to exist with another, and that it must be
accepted tentatively for the puipose of descrip-
tion only — ^
A Hypertrophic Catanh
R A ti opine Catairh
C Changes due to vanations in pressure
D. Changes due to deficient blood-supply
Oi the two chief forms the hypertrophic
originates in infancy and childhood, both sexes
being equally liable, the ultimate results being
seen m later life Adenoids are almost entirely
responsible for the condition The atr^hic
begins insidiously in young adult and early
middle hie, although it is occasionally met with
much earlier Young \\oinen are the chief
sufferers
The symptoms of both fotms in then later
stages aie closely similai, but, in unmixed cases,
the history and signs are \\idoly difteient , in
the hypeittaphic, definite changes are present in
the membrane \\ith Eustachian narrowing and
local and gencial signs of past or present nasal
obsti notion , in the atrophic, on the other hand,
little or no gioss change is obsened in the
membiane, there is no Eustachian obstruction,
and no apparent cause in the nose or naso-
phatynv A considciatinn of this subject indi-
cates the gieat nnpoitance of due attention
bi>m<j; paid to the condition ot the uppci lespna-
toiy passages in eaily hie
A HiPKRiitoPiiic ('\IARRH — Tins is a dis-
ease \\hich has its oiigin pimcipally in early
life, having Joi its chief chaiactcristics, deafness
associated \\ith definite changes in the mem-
biana tympam, and some pathological condition
in the none 01 naso-phaiynx
Causation — The CMUSCS must be any con-
dition wlmh will —
(1) Piedispose to attacks of acute (-atari h
(2) Tend to make acute cattmh become
ch ionic
(3) Maintain a chronic eatairh
These causes may be local 01 general, tho
local condition above all others is cluonic
hypertrophy of the naso-pharyngeal tonsil
(adenoids), a disease chiefly of childhood and
early life, al though not uncommon in middle
hie, and occasionally met \\itli at a much latei
penod Hypeitiophicd tonsils (although often
associated with adenoids), if they arc present
alone, will help to maintain a chronic catarrh
Othei local causes aic— -secondary syphilis, tine
or ialsc hypertiopliy of tho tiirbmal bodies,
suppuiation in accessoiy cavities of the nose ,
atiophic rhinitis , nasal polypi , irritation due
to noxious fumes, tobacco, etc The general
causes are — exposutc to wet and cold, antenna,
tubercle, in iact any disease which lowers the
vitality of the oiganism, tendering infection
easy, and hindering i etui n to a noimal condition.
JPatho/of/y — In considering the pathology of
this disease we will consider shortly what a
catarih is, and what changes are produced by it
1 But before doing so, the reader may be reminded
that the lining membrane of the middle ear
consists of throe layers • —
(1) Epithelial
(2) Sub - epithelial, containing lymphatics,
nerves, and, comparatively speaking, large
blood-vessels, and
EAR MIDDLE EAR, CHRONIC NON-SUPPURATIVE DISEASE
509
(3) A fibrous, which is adherent to the bone
An acute catarrh is an acute inflammation of
a mucous tnembidiio due to either injury 01
infection (.See p 483 ) At present we are
unable to way definitely what micro-organism
will produce catarrh, but, as far as w known,
any pathogenic organism has the power
The immediate result of infection is acute
swelling and reddening of the membrane duo to
the engorgement of vessels and the presence of
exudation, especially in the sub-epithelial layer
Exudation is also pouicd out from the surf aft,
being scions, sero-mucoid, or chiefly mueoid
At this point resolution may take place, leaving
no trace, the exudation in the Hiil>-epithelial
layers being earned off by the lymphatics, and
the \upsels returning to then noimal size But
if, from some local or general cause, icsolution
does not occur, the engorgement ot vessels con-
tinues and moie oi less exudation persists, th.it
which is poured out from the sui face being a
marked clinical feature in some c ases
The chionic engotgcment of \usscls leads to
local proliferation, especially oi the hbious
tissue in the sub-epithelial layei , this fibious-
tissuc prohfeiation undcigoes contraction, the
exudation ceases, the epithelial Lijei by stietch
ing becomes atrophied, and the whole lining
membrane becomes ultimately tomerted into a
LiU'i of thick hbious tissue
There ate theiefoie four stages which run one
into anothei when the acute pciiod is passed —
(1) Chronic engoigemcnt of -vessels with
exudation
(2) Resulting piohteiation, especially of the
fibrous tissue
(3) Ofmti action of the proliieiated fibious
tissue,
(4) The ultimate stage ot cicatiuial condition
which may be called post-eatai i hal
The results of such changes m the middle eai
can he easily imagined \\hen it is temembeied
that the lining membiane, besides clothing the
bony \\alls and innei aspect oi the mi mbi ane,
forms folds and Brackets lound the ossicles, then
joints, ligaments, and muscles
At fiist the ossicles and membrana tympniu
are hampered by the swollen membiane and the
exudation Later the couti aetion oi the pio-
hterated fibrous tissue causes luither <uid pei-
manent fixation
The membiana tympam is drawn in bj the
same cause, aided by the non-aciation of the
cavity through the Eustachian tube allowing
external atmospheric piessure to exeit its
influence The folds of lining membiane <ue
converted into fibious bands, binding do\\u the
ossicles to neighbouring walls, the nu us to the
outer attic wall, and the stapes to its niche
The tip of the handle of the malleus coming
in apposition to the promontory, the opposing
epithelial layers become rubbed oft and allow ot
adhesion at this point The ossicular joints be-
come anchylosed, the muscles fixed The exuda-
tion becomes inspissated or confined in pockets
of the lining membrane The Eustaclnan tube,
sharing the same changes, becomes nan owed
So that an originally pink, moist, thin, some-
\v hat movable lining membrane becomes smooth,
u hite, clry, and thick Further changes of the
lining membrane sometimes occur, such as
calcification, fatty degeneration, etc The tensoi
tympam and stapedms muse le& undergo atrophu
degeneration
As the trouble may be limited to the Eus
tachian tube, 01 may involve the \vhole middle
ear tract, each Mill be consideied separately
with their sj'mptoms, signs, prognosis, diagnosis,
<uul treatment, as fat as possible m then
diilerent stages
(a) C/norur Eu^tar/nan Cutatrh — This may
be limited to the onfice oi the tube, or extend
some distant e up the cartilaginous poition If
long continued, changes ma_y take place in the
\vholo tract , these \\i\\ bo considered under the
changes produced by vanations in pressure
(p 516)
tfymptonv* nttd tin/n* -One 01 both ears may
be affected , it both, one is ofttn \\orse than the
other Deainess is marked, but may \aiy from
time to time, impiovmg sometimes on swallow-
ing or on blow ing the nose, but the nupiovenicnt
soon disappears or li ]xii maiient changes have
not occiiiiccl, the patient, aftei suffering foi
-.ome time, may feel a uack in the eais with
subsequent complete restcnation of healing
On inflation \\ith I'uht/ci's bag or the Eus-
tadnan cathetei immediate and permanent
nnpio\ement may occui in the limited early
static , or if the disease is ot long standing,
(•specialty it it has extended some way along the
tube, difficult} ma> be expeiienced in getting
the tube open, and the. lesiilting unpi o\ eiiiont,
though gieat at the time, soonei or latci dis-
appeats On listening with the auscultation
tube dining inflation the an can be heaid at
hrst m the distance entcrim* N\ith difficulty,
befoie clearly entering tho ttvvity oi tho tym-
panum In the exudation stage distant bubbling
may be at hrst heard The patient complains
ot a distinct feeling of oppiession oi the head
on the side affec ted , and mental dull less may
bo felt, especially li both tubes are blocked
Tinnitus oi a lushing charattei is heaid The
patient's own \oiee sounds to him louder on the
atte<_ted side, and if both eais tire implicated it
seems as li he were talking into a hollow \essel
The auntie and sunoiindmg paits feel numb
w hen lightly tombed On looking at the mem-
biana tympam all the signs of depression will be
scon If peimaneut changes in the middle eai
have not been pioducctji the. pink lining mem-
biane may show thiough, unless any opacity is
pieseut The white, shoit piocess of the malleus
is prominent, the handle foreshortened and
di aw n somewhat backwards The i olds m nmng
508
EAR- MIDDLK EAR, CHRONIC SUPPURATION AND SEQUELS
with stops of lodoform gauze. Its proximal
end should also be scraped and a stream of warm
carbolic lotion (1-40) syringed along its com so
until it flows freely thiough the divided end of
the jugular vein in the neck Antiseptic dress-
ings are then to be applied in the usual \\ay
The packing within the sinus should bo allowed
to remain in situ foi five or six days, and then
should be carefully rcmoxed If neeobbary the
sinus may be repacked
Septic JSncejtkttliti* — As has .iheady been
mentioned, the brain tissue in the neighbour-
hood of the suppurating focus may itself
become inflamed, as is evidenced by oxlematous
swelling, softening, diffuse suppuration, and
increase of mtracraiual tension
Ttentnient consists in eradicating where
possible the piimary cause, in treating the
seeondaiy focus of biippuiation \\ithm the
cranium, in antiscptically cleansing the sup-
purating ccrcbial suif.ice, <ind in providing
fice di ainage
Middle Ear
Disease
Chronic Non - Suppurative
INTHOHDC ion*
IlYI'KRTROFIfir CArAKUIl
(a) Chronu Eu*tachmn Cataith
(ft) Chtonn Ctiktrt/i in Mit?t?lt En,
Tnitt
1 Matfc of £n</<m/t>nu>nf
"2 »SVfif/ps of Ptolttnatwn >i»d
Contraction
3 Cicnhicial or Po\t-(1<it«)ihnl
Shu/e
(t) Ojmative Mea*utt\
ATR< >i»H ic ( J VTARRIJ
CHANGES PRODUCED in VARIATIONS iv
r>08
509
510
510
DKMPIKNT
512
r>U
3U
51 G
o!6
UNDER this title aie descubed all cases of
deafness due to middle ear disease, in \\lnch the
mcmbrana tympani is intact
Although gicat advances \\A\Q of late yeais
been m.ulo m sepaiatmg the different foims, we
are as yet unable, in many instances, to diaw
haid and fast lines between them, thus lendei-
mg description extiemely difficult and often
bewildering The chief difficulty oxpeiieuced
in studying them is, that the oppoitumty foi
pathological examination, m then eaily stages
especially, is raiely obtained
Tn adopting the following classification it
must be u IK lei stood that one form often appears
to exist with anothei, and that it must be
accepted tentatively foi the puipose of descrip-
tion only — tf
A Hypei trophic Catarrh
B Atiophic Catarrh
C Changes due to variations in pressure
D. Changes due to deficient blood-supply
Of the two chief forms the hype* trophic
originates in infancy and childhood, both sexes
being equally liable, the ultimate results being
seen in later life Adenoids are almost entirely
lesponsible for the condition The atrophic
begins insidiously in young adult and early
middle life, although it is occasionally met with
much eai her Young women are the chief
sufferers
The symptoms of both forms in their later
stages sue closely snnilai, but, in unmixed Crises,
the hibtoiy and signs are widely different, in
the hi/perti <>/>hic, definite changes are present in
the membrane \uth Eustachian nai rowing and
local and geneial signs of past or present nasal
obstiuction , in the attop/nc, on the other hand,
little 01 no gross change is observed in the
inembiaiie, there is no Kustachian obstruction,
and no apparent cause in the node or naso-
phaiynx A consideration of this subject indi-
cates the great impoitance of due attention
boiiig p.ud to the condition of the uppoi lespiia
toiy passages in early life
A Hu'ERTKOPHie (J \TAiiRH — This is a dis-
ease \\hioh has its ongin pimuipally m early
life, I Living foi its chief chai.ictenstics, deafness
associated uith definite changes in the mem-
hi ana tympani, and sonic pathological condition
m the nose or naso-phaiyn\
Caiiwhon — The causes must be any con-
dition whuh will —
(1) Picdihposc to attacks of acute catarrh
(2) Tend to make acute catarih become
chionic
(3) Maintain a chronic latauh
Thew causes may be lo< al 01 geneitil , the
local condition aboAe all otheis is chronic
h \ pci trophy of the naso-pharyngeal tonsil
(.idenoids), a disease chicHy oi childhood and
early life, although not uncommon in middle
life, and occ.isioii.illy met \v ith at a much later
period Hypi^rti opined tonsils (although often
associated with <idenoids), if they are present
alone, will help to maintain a chronic catarrh
Othei local causes are — secoudaiy syphilis, true
or false hypei trophy of the tmbmal bodies ,
suppuration in aeeessoiy cavities of the nose ,
atiophic ilnmtis , nasal polypi , nutation due
to noxious fumes, tobacco, etc The gencr.il
causes are — exposure to wet and cold, anucnna,
tubetcle, in taet any disease which lowers the
vitality of the organism, rendering infection
easy, and hindering return to a normal condition.
Pathoht/y — In considering the pathology of
this disease we will conmdei shortly what a
catairh is, and \vhat changes are produced by it
But before doing so, the reader may be reminded
that the lining membiano of the middle ear
consists of three layeis —
(1) Epithelial
(2) Sub - epithelial, containing lymphatics,
nerves, and, comparatively speaking, large
blood-vessels, and
EAR MIDDLE EAR, CHRONIC NON-SUPPURATIVE DISEASE
509
(3) A fibrous, which ib adherent to the bone
An acute catarrh is an acute inflammation of
a inuoouH membrane duo to either injury or
infection (See p 483) At prcbent we are
unable to H,iy definitely what micro-organism
will produce catarih, but, as far as is known,
any pathogenic organism has the power
The immediate result of infection w acute
swelling and reddening of the membrane due to
the engoigement of vessels and the presume ot
exudation, especially in the sub-epithohal layei
Exudation is also poured out from the smfau»,
being serous, sero-mucoul, 01 chiefly mucoid
At this point resolution may take place, leaving
no tiaco, the exudation in the sub-epithelial
layers being earned off by the lymphatics, and
the ^vessels returning to then normal size Jttit
if, from some local 01 general cause, resolution
docs not occnt, the engoigement of vessels con-
tinues and moic 01 less exudation peisists, that
which is poured out from the sin lace being a
maiked clinical feature in some cases
The chronic engorgement of \essels leads to
local proliferation, especially of the fibrous
tissue in the sub-epithelial layor , this fibious-
tissue proliferation nuclei goes contraction, the
e\ud«ition ceases, the epithelial lajei by stretch-
ing becomes attophied, and the whole lining
mcmbiiino becomes ultimately ion\ei ted into a
la\ei of thick fihious tissue
Theic an* theiofoio fimi stipes which run ono
into anothei when the acute penod is passed —
(1) Chronic, ongoigomcnt of vessels with
exudation
(2) Resulting proliferation, especial!} of the
fibrous tissue
(3) (>t>ntiaction of the piohfeiated iibious
tissue 9
(i) The ultimate stage ot cicatiicul condition
which may bo called post-catanhal
The results of such changes in the middle ear
e an be easily imagined \\hen it is lemcmbeied
that the lining membiane, besides clothing the
bony walls and mnei .ispect oi the membiane,
fin ins folds and pockets loiind the ossicle's, then
joints, ligaments, and muscles
At first the ossicles and membrana tympt in
are hampered by the swollen membiane nnd the
exudation Latoi the conti action oi the pio-
liteiated hbious tissue causes fnxthci and pei-
manent fixation
The membraua tympam is diawn in by the
same cause, aided by the* non-aotation of the
cavity through the Eustachian tube allowing
external atmospheric pressure to e\eit its
influence The folds of lining membrane are
converted into fihioiiH bands, binding do\\n the
ossicles to neighbounng walls, the incus to the
outer attic wall, and the stapes to its niche
The tip of the kindle of the malleus coming
in apposition to the piomontory, the opposing
epithelial layers become rubbed off and allow ot
adhesion at this point The ossiculai joints be-
come anchylosed, the muscles hxed The exuda-
tion becomes inspissated or confined in pockets
of the lining membrane The Eustachian tube,
sharing the same changes, becomes nai rowed
So that an originally pink, moist, thin, some-
what movable lining membrane becomes smooth,
white, diy, and thick. Fii'ther changes of the
lining membiane sometimes occur, such as
calcification, fatty degeneration, etc The tensor
tympani and stapedius mus< les undergo atrophic
degeneiation
As the tumble may be hunted to the Ens-
(achian tube, 01 may imohe the whole middle
eai tiact, each will bo considered separately,
\\ith then symptoms, signs, prognosis, diagnosis,
<i id treatment, as fai as possible in then
oifteient stages
(<t ) ( 'hi wir Eu star hum < 1<itai rh — This may
bo limited to the ounce ot the tube, oi extend
some distance* up the caitilagmous poition It
lonir continued, change's ma} take plate m the
whole tract, these \vill bo considered under the
changes pioduced by % aii.it ions in pressure
(P 516)
tfymjtttani ntul Mtyn* — One oi both ears may
be affected , if both, one is often worse than the
othei iHMfness is marked, but may xaiy from
time to time, impiovmg .sometimes on s\> allow-
ing 01 on blowing the nose, but the nnpiovement
soon disappcais , or if permanent changes have
not occmied, the patient, aflci suffering foi
^ome time, m,iy feel a ciack in the eais with
subsequent complete i catenation ot hearing
On inflation with Polit/ei's bag oi the Eus-
tachian cathctci immediate and permanent
impro\ement maj occur in the limited early
stage , or it the disease is of long standing,
especially if it has extended some way along the
tube, elithe ult\ may be cxpeneuced in getting
the tube opi 11, and the lesultmg impiervement,
thoimh gieat at the time, soonei or latci dis-
appe.us On listening with the auscultation
tube duiuig inflation the ait can be heaid at
fust in the distance entering with difficulty,
before cleaily enteiing the cavity of the tym-
p mum In the ex udation stage distant bubbling
may be at hist heaid The patient complains
ot a distinct feeling of oppiossion ot the hood
on the side affected , and mental dulncsH may
be felt, especially if both tubos aie blocked
Tinnitus ot a lushing chain* tei is heard The
patient's own %oic-e sounds to him louder on the
aflcctcd sick*, and if both cais aie implicated it
scorns .is it he weie talking into a hollow vessel
The auricle and suiiouncjing paits feel numb
when lightly touched On looking at the mem-
biana tympani all the signs of depiession will be*
seen It pcimanont changes in the middle eai
have not been produce^ the pink lining mem-
biane may show Ihiouuh, unless any opacity is
picsent The white, shoit process of the mu Ileus
is prominent, the handle foreshortened and
di awn somewhat back\\ ai ds The folds running
510
EAK MIDDLE EAR, CHRONIC NON-SUPPURAT1VE DISEASE
forwards and backwards fiom the shoit process
to the periphery are marked, the latter especi-
ally. The triangular light loflcction fiom the
tip of the handle of the malleus is mtcirupted,
shortened, or absent, depending upon the
amount of depression The structuies in the
middle ear and the mnei \\all may be clearly
visible. In the posterior and superioi segment,
the descending piocess ot the incus with the
stapednib muscle running baekwaids from close
to its tip, the chorda tympaui nei\e i mining
from behind upwards and foiw.iul& across the
descending process ot the me us, may be seen
Tho smooth curve of the promontoiy in tho
infenoi scgmont is well maiked, and below and
behind it the round \\iudow appeals as a daik
patch On looking at the naso-phaiynx a
catarrhul condition of the lining membrane may
be seen, it being led and swollen \vith exuda-
tion ly my on its surface Sometimes this (.in
be wen mvohmg the lips and onfice of the
Kiibt.ichi.iii tube , ,uid lately a plug ot exuda-
tion may bo seen Ijmg in the ontice
Ptojjnovs — In the eaily stages this ih veiv
good , m the laU r it will depend on the amount
of constriction produced, and uhothoi the tjm-
puumi is also imohed
Diaynfws — Simple chronic Eustaehian
catairh \vill be diagnosed by the marked im-
provement of heaimg by inflation and the
absence of permanent changes in the membrane
The general methods of diagnosing middle from
internal ear affections aic described on page
Tteittmrnt —Anv causes in the nose or n«iso-
phaiynx must lie lemoxed, and treatment
diiected to iiiipiovmg the patient's general
condition adopted, such as change of an and
tonics In the cuily stages a single inflation
may be all that is necessaiy to open a tube
which has been pel haps bloc ked by a plug of
mucus, or the sides of \\lnch ha\c stuck
togcthei If the tioublo has extended some
distance up the tube, inflation will have to be
repeated, the intervals between the pioceed-
mg depending on the effect produced and
the length of time improvement in hearing
leniams
In thelatei stages, \vhcn contraction appeals
to become a definite feature, cs[w;cially if the
cartilaginous portion is affected, injections of
alkaline solution 01 of paioleme, or the passage
of a bougie through the Eustaehian catheter,
may be necessary " Combined \vith this treat-
ment tho chloride of ammonium vapour, ob-
tained by means of Godfrey's or Basdon's inhaler,
drawn into the mouth and blo\\n through the
nose for ten minutes night and morning with a
few auto-inflations into, the middle car by means
of Valsalva's method when the mouth and nose
are full of vapom, is often of great use
An alkaline and astringent solution gently
syringed down the nose after tho inhaler is
often useful. In tho last stage it will usually
be found that further changes in the upper
middle oar tract have occurred either by ex-
tension of tho catanh, or by changes produced
by the vaiiation in pressure The treatment in
these cases will bo considered later
A useful point, when difficulty of opening
the Eustaehian tube by ordinary inflation is
experienced, is to place a few drops of pure
chloioform into the bag betote inflation
(ft) Chronic /fypet trophic Catanh in the
whole Mull It Ear Ttnct — Symptoms ttnd
»SV///s — These \\ill depend on how far the
disease has piogressed
1 tftm/e ot Chioiuc J£n<ioi</eme>it of Veawl*
with Stwtatum — Although a ceiUiu amount
ot exudation from the surface is picsent m all
cases, yet in some it forms a vciy prominent
(linital feature demanding special desciiption
It must be stated that eases of this xaiiety aie
undoubtedly laie in (Jieat Hi i tain It is im-
possible to hay what detet mines this excess of
exudation , undoubtedly m some c ases the
excess is moie ippaient than leil, being due
to the collection of exudation in the t>mpaiiuni
owing to <oexistmg Kustarhian obstruction
The chaiaott'i of the exudation \aiies, being
serous, scio-mu< old, 01 muooul , and here also
it is impossible to say definitely on \\hat the
xaijing characteis of the exudation depend
The history of these eases in \v Inch t rwht-
tion it mailed nsuallv is th.it, aftci an acute
catairh of the naso-phaiyirx, deafness in one or
both eais persists The exudation form may l>e
piesent on the one side, \\\\\\ simple Eustachian
obstiuction on the other Thcio is a feeling of
fulness in the eai, stoppmu shoit cA actual
pain, and a sensation of something moving,
especially if the exudation is serous, \\ ith occa-
sional bubbling, especially after blowing the
nose Imprn\emcnt in hcaimg occurs tem-
poranlv, but is only of shoit diuatioii, and may
vary \\it\\ the position ot the hoad The patient
may heai bubbles bursting, ospccicilly after
inflation Hushing and occasionally pulsating
tinnitus is present The he.ul on the affected
side feels heavy, and numbness of the auricle
and surrounding parts is experienced The
patient's own xoice sounds unusually loud
Inability to do mental \vork is often complained
of , and sleep may be disturbed, owing to the
bubbling and cracking which goes on in the
ear When the mucoid element predominates
bubbling and vanations on posture are not
marked
Sometimes, especially in old people, the mem-
brane may rupture on blowing the nose or on
inflation, producing perhaps a suppurative
piocess icsulting fiom septic infection from
the meatus In infancy and early childhood
rupture seems teadily to take place m the early
stages
On examination the appearance of the rnena-
EAR MIDDLE EAR, CHRONIC NON-SUPVURATIVE DISEASE
511
braiie varies accoidmg to the chaiactci and
amount of the eMidation, the length of time
it has been present, and the clegiee of clearness
of the membrane
If the exudation is slight and seious tlie
malleal vessels aie somewhat injected, and the
fluid can he been occupying the lo\vei pait , its
upper lex el, which appeals as .1 thin cl.uk line,
vaiymg with the position of the head , ox it
greater in amount, maiked bulsjring, usually in
the pobterioi segment, is seen, peihaps com-
pletely hiding the handle ot the malleus On !
inflation, a disturbance of the fluid can he seen |
with the ioimatiou of bubbles , ox if the auscul- I
tation tube be used, clear bubbling tan bo j
heaid If the mucoid element pieponderates, a j
whitish -yellow appeal ance of a moie 01 less
bulging memhianc is seen with dilated \esseK
couising o\ei , theie is little oi no moximcnt
obsei vable on postuie, and on inflation thiough
the catheter, ,is the bag is oiten not elleetne,
the an ean be heaid at hist in the distance and
then gi adually to entei the tympanum with
stukv i Ales
In the latei pi»iuxl of the evudatne stdue the
exudation paitlv escapes fioin the Eust.u'hian
tube, while some becomes inspissated, — the
inemhianem the me.in\\lnle beeommg pale and
depiessed, \uth perhaps localised collections of
exud.it ion
In those case's in which titu/ation <s not a
mat Iced clinical fcatuie the svmptoms and signs
aie not so augicssixc Deafness, impiovmg on
blowing the nose, with giadual letuin to the
foimci condition, and tinnitus of a i ashing «md
puls.itmg (hai.utei, .ue c oiiipLuncd of The
membiaue is some\\h<it di«piessed, the lining
membrane seen thiough being daik pink in
colom* On inflation slight bubbling may be
heaid, the impi ON emcnt in healing pioduced
l)emg gieatei <md moie Listing than in the
cases oi maiked exudation
PtwjiiMi* — This, if the ease be piopeilv
taken in hand, is as «i inle excellent, but if
long-continued 01 untreated, lesulting in furthei
changes in the lining membiane, as elemon-
sti.ited chiefly bj the amount of nnpio\ement
in hearing produced by efficient inflation, len-
ders it pi opoitionatcly worse , theiefoie befoie
giving a definite opinion in long standing cases
it in well to \vait the effect of ticatmcnt
DutgnoBis — The cases of maiked exudation
give definite signs
From a collection of pus they ate diagnosed
by the absence of acute lednews of the mem-
brane, chromcity, and the absence of pain and
fever If the exudation is mucoid, a general
whitish appearance is seen instead of a xellow
or greenish yellow, which is seen when the
contents of the tympanum are piuuleut The
effect of treatment will also help In those
cases in which exudation is not a marked
clinical feature bubbling is sometimes heard,
and the unusually daik and swollen lining
membiane seen through tho mcmbraua tympam,
togcthei with the persistency of the symptoms
and effects of inflation, maik them fiom simple
Kustachian obstruction
Ttentnwnt — At this stage, as we ha\c seen,
it is possible for the disease to be completely
ariested, and no means should be spaied to
prevent fuither piogiess The tieatment is
local and geneial 1 hose cases in which vjudu
lion is marked will be fust considered
If this is slight .iud seious the treatment
adoplea foi simple Kustachian cutairh will
sufhce As before stated, it is impossible
at fust to siy how much Kustachian obstrut
t'on is H-sponsible foi the collection of
c'viidation in the tympanum j sometimes cases
which .it hist appear to demand moie ladical
measure's yield to simple treatment In the
cases in winch simple lemedies do not effect a
cine, i collection oi exudation persisting, and
especially when the mucoid element pre-
dominates, they must be supplemented by
intia-Umpanic injections of warm steiile alka-
line' solutions, such as bu.irbon.itc of soda,
live gi.uns to the ounce-, oi of paioleme
Countei -nutation behind the eai, ox massage
f loin above downwards behind the eai and
uppei part ot the neck, may also be used 11
these measines do not suffice, the membrane
must be opened, peihaps moie than once, as
the incision speedily closes in spite ot inflation
The incision must be made undci stiict anti-
septic piecautions, thiough the pait in which the
bulging is most maiked, 01, if no bulging is
piesent, in the posti'iioi and mfciioi segment,
it should be iiec and paiallel to the handle of
the malleus At the tune of incision inflation
should be piactised to cleai the middle1 eai, the
exudation being then gently mopped out The
mcatus should then be lightly plugged with
the antiseptic diessmg The simple tieatinent
of the nose and naso-phaiyn\ with the chloride
of ammonium inhalei and nasal solution should
be continued meanwhile Massage by means of
Siegle's speculum will be found useful in hasten-
ing absoi ption and piev enting adhesions Change
of an to a hitih and dry climate with tonics is
often very benehc ul
In those cases in which eiutlatwn is not
mailed, simple tieatment, xegulai inflation,
massage of the membiane, together with tonics
and change of air, will usually bo found suffi-
cient In these cases, again, local tiouble in
the nose or naso-phaiynx must also be removed
2 rihu/es of Prohfetation nnd Contrwtwn —
In discussing the following stages they merge
so gi adually, one into the other, that it is
impossible to separate tthem completely, the
progiess of the eases being judged according to
the amount of nnpiovement obtained by treat-
ment and the changes piesent m the membrane
We may discuss the st.iges of proliferation and
512
EAR. MIDDLE EAR, CHRONIC NON-SUPPURATIVE DISEASE
contraction together This is a common period
for patients to present themselves for treat-
ment, as they find that the deafness, which they
thought would pass off m time, has not only
persisted, but is gradually getting worse
Symptoms and Supi* — The histoiy of these
patients, usually young adults, is that deafness
has persisted aftei a cold or series of colds, 01
has giadually come on since , 01 th.it in child-
hood occasional deafness was noticed, with a
history that points strongly to the fact that
adenoids weio present at that penod In fact
they often present the appearance due to chronic
nasal obstruction They also state that they
aie worse w ith every cold, w ith pei haps marked
permanent deterioration In the later btage,
when far advanced, the symptom of hearing
better in a noise may begin to show itself,
indicating the gradual onset of the fixation
stage Deafness is well marked, both cam as a
inle being aftocted, one, often the left, being
the worst- The fact that the patient cannot
hear genetal comcisation, or when at a dinnci-
party,he cannot hear conveisation distinctly on
one side, may be the symptom which compels
him to come foi tieatment Tinnitus, lushing,
i oaring, clanging, or machinery-like m character,
is often a souice of gicat trouble, being wora»
when the patient is quiet, especially at night,
sometimes preventing sleep
Diplacusis, usually disharmony, is sometimes
complained of On examination the1 membiane
is pale, often opaque, with peihaps patches of
chalky deposit (phosphate ot lime), the signs of
depression being matked, and in the later btagc
the pink lining membrane cannot be seen, e>cn
if the dium IN clear
On applying Siegle's speculum it will be
found that the membiane .md malleus do not
move freely, 01 peihaps the posterior segment
\\ill alone be freely movable On inflation
thiough the catheter the air will be heard to
enter with difficulty and diyly, with perhaps a
whistling sound The amount of improvement
in heating produced will vaiy accoiding to how
far pathological changes have piogicssed On
examining the membrane after inflation little or
no alteration is seen The nose 01 naso-pharynx
may present some pathological condition, and it
is often possible to detect, even in middle life,
remains of adenoids, which if seen during a cold
may be considerable in si/e
Pror/nosts — Foi this we lely upon the pro-
gressive chaiactei of the de.ifncss, which is
worse with each cold, and the absence of internal
oar trouble as shown by the tuning-fork, etc
Fiom the exudation stage, by the absence of
moist sounds on inflation, the depression, fixa-
tion, and opacity of ,the membrane, and the
amount of improvement produced by inflation
From the last stage, by the amount of improve-
ment pioduced by inflation, the absence of
paracusis, which, though present m the later
stages of con ti action, appears to indicate that
the final stage is being reached
Treatment — if on inflation the improvement
in heating is marked, we gather that the con-
traction stage has not advanced far, and we
must adopt treatment which will, as much as
possible, cut short the ptoliferatiou or limit the
amount of contraction
In older to do this, definite local ttoubles in
the naso-pharynx or nose must be removed,
followed by regulat inflation by means of the
bag or Eustachian catheter, the intervals be-
tween the inflations being judged by the length
of time improvement in hearing lasts Massage
by moans of Sieglc's speculum or Delstanche's
massciu is also useful The chloiide of am-
monium inhaler and the nasal solution, with
tonics and change of an to a high and drv
climate, should be combined with the other
trentment
If the Eustachian obsti uction is a piozmneut
feature a Irougie may be paused up the tube, or
parolcme may be injected thiough the catheter.
It the results pi od need by this treatment aie
not great we must infei that contraction is well
achanoed , and we may have to considei, if the
deafness is extreme, the question ot opoiative
tie.itment, which will be presently dealt with in
considei ing the tieatment of the post-catarrhal
stage
Sometimes iodide of potassium in small doses,
combined \\ith ammonia given in hot watei
twue a da> foi a foitnight ot three weeks, pro-
duces good tesults With regard to tinnitus,
the tieatment we have indicated will usually do
as much good as is possible, as it is mechanical!)
pioduccd and depends on the local changes
Tonics aie useful in rendering the patient moie
able to stand the noises , bromide of potassium
and diluted hydrobiomic acid are sometimes
useful .is sedatives Electnuty may bo tried
if at the fitst sitting neither the anode noi
cathode .liters the sound the case is unf a voi li-
able , but it the noises are diminished during
the passage of the auodal cm tent, the treatment
is moie hopeful and should be continued (Lewis
Jones, Archives of Otology, vol xxiv )
3 Ctcatrtcial 01 Po*t-C<it(irthal titaqe —This
may be looked upon as the ultimate condition
lesulting from the unchecked pi ogress of the
disease, which may ha\e occupied a longer or
shoi tot length of tune
8ymj>t(miv and tin/it* — A history of gradual
increasing deafness of catarthal oiigm, distinctly
worse on colds, until a pitch ot deafness has
arnved which, although never absolute, necessi-
tates a loud voice close to the ear. Paracusis
Willisn, or hearing better m a noise, is a promi-
nent symptom, this phenomenon is supposed
to be due to vibration produced by jolting or
by loud noises, enabling the rigid ossicular
chain to more readily transfqj sound waves
Occasionally the patients will state that they
EAR • MIDDLE EAR, CHRONIC NON-SUPPURATIVE DfSKASE
513
used to hear better in a noise Tinnitus is
often very distressing, sometimes rendering life
almost unbearable, and in a few even suicidal
tendencies may be present The patients are
morose, introspective, being to a large extent
cut off' from the outside world Many acquire
in some degree the power of lip reading, and
they will consequently hear better when the
speaker is facing them A low Imt clear voice
is heard better than shouting High tones will
be distinctly heard better than low , for instance,
a watch will be heard comparatively better than
the human voice On looking at the membrane
it will appear markedly depressed and opaque
By means of Sicglc's speculum the malleus may
be firmly adherent to the promontoiy , the
membrane peihaps fixed to the descending pio-
cess of the incus and round the malleus to the pro-
montoiy On inflation the air enters with difficulty
and produces no change in the position of the
malleus 01 membrane Impio\ementinheaiing
is cither absent, 01, if slight, is of shoit duration
Diminution of the noise is sometimes produced
Proynons — Is extremely bad as regards hear-
ing and tinnitus , de«iincs>> is never absolute,
and the patient may become more or less used
to the noises, which may \ary with the state of
health Operative measures may produce ini-
piovcment, if not in hearing, in tinnitus
Dmtjnosis — From th« pre\ious stages it may
bo diagnosed by the fixation of the membrane,
the obstruction of the tube, the paracusis,
and the slight nnpro\emeiit on inflation The
tumng-foik andtone-heaimg tests \\ill distinguish
it fiotn internal oai disc.ise, but \\e occasionally
find that the tuning-folk m these cases indicates
a cei tain* amount ot internal ear implication,
the histpiy of patacusis will be sufficient to stamp
the case* as having 01 igmated m the middle eai,
especially if othei sj mptonis of internal esu dis-
eases are absent Ti uo auditoiy ^ ertigo does not
occui
Treatment — It follows from the pathological
condition that ordinal y local and general treat-
ment is useless 111 eflecting useful or any per-
inanent improvement in hearing or tinnitus
The treatment, howevei, described under the
pievious stage should bo given a fan trial If
the patient is satisfied with the tempoiary and
slight impiovement which may be effected,
especially if lip- reading lessons are taken,
ordinary methods of treatment should be fiom
time to time employed
(c) Operative Measures — liefore undertaking
operative measures care must be taken that the
internal ear is intact, and it must be pointed out
to the patient that they are more or less of tin
experimental nature It m well to fully explain
to the patient the true condition of things, and to
leave it to him to decide as to whether they should
bo undertaken It is wise to first operate on
the ear which is more affected These intra-
tympamc operations fall under three headings —
(1) Those undertaken to icheve tension
(2) Those undertaken to dimmish undue
flaccidity
(3) Those undertaken to allow sound waves
to reach the fenestne direct
None of them should be undertaken without
stuct antiseptic precautions
(1) Thcw wrulertaLen to relieve Tension —
These comprise division of adhesions, section
through the pos tenor told, tenotomy of the
tensoi tympam, and division of ligaments
These have not realised expectations, any im-
provement which is produced speedily disap-
pearing <IH scxm as the inevitable healing takes
place , therefore they may be placed on one side
f'2) 7V/OSC vjvkrtaken in cases of undue
i&idity — When the membrane or some
part of the membrane is seen by inflation or
the Sitple's speculum to be unduly flaccid, due
to atiophy 01 to energetic inflations, or the
result of a cicatm, especially if marked im-
provement m hearing occui s when it is put on
the stretch, multiple incisions made thiough
tho flaccid part with the idea of producing
eicatucial contraction may be undertaken, but
the result is often disappointing Collodion
painted ovei the flaccid poition and adjacent
meatal wall may bo of bcneht
(3) 7%o«*«McfofcfX'A to filtow of tfound Wave*
imchinr/ the Feneitra' direit — It has long been
known th.it the artificial pciforation of the
memhiane will m some cases produce great nn-
piovement in hearing, but as healing always
takes place, and no method of keeping the
perforation open has yet been devised, some
furthci pnxediue becomes necessary As to
whethei further proceedings should be .ulopted
e\ploratory tympanotomy is a useful guide, for
if it produces improvement in heaimg or
tinnitus, we aie encjiuaged to pioceed to more
ladical measures, but e^cn if it does not, and
given that the intcinal ear is intact, and the
case is not one of atiophy, we may, if the
patient so doanos, adopt tho moie radical
measures, as it may mean that the absence of
improvement is due to fixation of the stapes, or
to blocking of the round window to cicatncial
tissue
JZr/tloiatory Tymjuwtomy — This little opera-
tion is best performed under gas anesthesia,
by cutting a fl.ip with its ape,\ uppermost m
the posterior and supenoi segment, by means
of a sharp-pointed kmie, under a good reflected
light
Preliminary inflation of the middle ear may
be useful in separating the memhiane as far as
possible horn the middle eai wall Further
procedures can be divided into two stages —
(a) Reruov.il of the membrane, malleus, and
incus, which if not productive of improvement,
even aftei an artificial membiane has been tried,
may be followed by
(fy Mobilisation or removal of the stapes,
514
EAR: MIDDLE EAR, CHRONIC NON-SUPPURATIVK DISEASE
and removal of cicatncial tissue from over the
round window
(a) The JKentovaf of the Mem/>ran,e, Malleus,
and Incus. — This should be peifoimcd under
a general anaesthetic, the head being slightly
raised on a pillow and turned thiee-quarters
over to the opposite bide A good reflected
light 18 necessary An incision is made with a
sharp-pointed knife, starting fioiu immediately
behind the short pi ocean of the malleus, sweep-
ing round as close to the periphery as possible
to a corresponding point on the antcrioi aspect
of the short process The handle is then fieod
from adhesions which may be pic set it between
the membrane or malleus and the pionumtoiy
The tensor tympani is then divided, cither b}
Delstanche's extiact or by a small cui\cd knife
The malleus is then sei/ed as high up as possible
with a pair of stiong curved foiceps, being
pulled first down \\aids to tree it from the attic,
and then outwards The incus must then be
turned out horn, the attic by means of an incus
hook, which, being introduced into the an tenor
part of the cavity, is lotated downwaids and
backwards, pushing the ossicle into the lo\\ei
middle Cfir, when it may be remo\ed by loiceps
or by syiingmg
Numerous incus hooks die nude, the most
useful being either Delstanche's, Lake's, 01
Ludewig's The middle eai should then be
gently mopped out, a gauze diessmu> bhould be
lightly introduced into the meatus, and a
general dressing and bandage applied It anti-
septic precautions have been efficient, dressing
will not be required foi a Meek or ten dajs
At the end of a fortnight or three weeks the
hearing powoi should be tested again, and the
amount of tinnitus noticed The dressing
should not bo left out until healing is complete,
when an artificial membiane maybe tried if no im-
provement lesults Sometimes an adventitious
membrane foims acioss, annulling any good
effect, and may leqiurc lemoval more than once
(6) Moliilwtton and t/te Hemouil oj the
Stapes awl t/te Removal of Cuatrtttal Tiu>ue
prom ovft the round Window* — Befoio these
operations are peifoimed the eai should be
allowed to heal soundly, allowing the condition
ot the inner middle wall to be plainly seen
Adhesions binding do\\n the head and cinia of
the stapes should be divided with a fine shaip,
shouldered knife, such as Pulitzer's, as close to
the ossicle as possible, under eucaine or cocaine,
the stapedius muscle being also divided, and the
Htapes mobilised by means of a suitable piobe
It improvement occuis, nothing more should be
done , if it does not, we may again try an arti-
ficial membrane, if this is meffectrvc wo should
lemove adhesions obscuring the round window
as fai as possible, a rathei difficult proceduic
on account oi the anatomy of the part If this
is insufficient we must infer fixation of the base
of the stapes c
With regard to removal of the stapes more
experience and investigation is necessaiy
If mobilisation has not been possible, at-
tempted removal will, in all probability, result
in fi act ure of the crnra, leaving the foot-plate
still in position The attempted removal should
be made by means of a hue hook introduced
between the ciura from above, and with a gentle
side to side movement It may be that, in the
future, operations on the innoi middle ear wall
may be of benefit A more radical method has
been proposed and earned out by Malherbe,
who opens the antiiim from behind, divides
adhesions in the middle car, and introduces a
celluloid tube through the meatus into the
antrum (Piucenimy* of t/ie faith International
CW/jes* of Otolw/y, 1899), the lesults have
not been brilliant, and until iurthci experience
has been obtained it may bo fairly stated that
operations thiough the meatus, as described,
aio equally clhcieut
Jl AiHoL'iiic CATARRH — Fuation oj tftape*
- -The chief ehaiaeteiistics of this foim .Are the
very giadual and insidious onset of deafness,
with little or no change in the membrane and
no obvious cause in the nose or naso-pharynx ,
the majority of c ases oc currmg in women between
the ages of twenty and foity
Cnuwtitm — The causes aie obscuie in the
highest degicc Ileiedity is certainly an im-
portant factor Occasionally a vague histoiy of
a bad cold or series of colds is obtained as a
starting-point Some seveie illness, such as
iheinnatic fever, is thought sometimes by the*
patient to be the origin, and occasionally chiomc
ihounmtiu affections .ire coexistent AntJLinia is
often piesent Paztuiition is mtinutely con-
nected with this class , the deafness eithci
apparently commencing aftei Liboui, 01 being
made consideiably and peimaneutly worse
the.ie.by
Pathology — This appeal. s to be an atiophy of
the lining membiane with a marked tendency
to the fixation of the base of the stapes in the
oval window, and sometimes implication of the
inteiual ear in the later stages The onset is
so giodual that pathological investigation in
the early stages is well-nigh an impossibility,
we an» only familiar with the ultimate results
produced On lemovmg the roof of the middle
eai affected with the disease, the first thing
that strikes one is the widencss, whiteness, and
dryness of the whole cavity, the contained
stiuctures being cleat ly defined Fine mem-
btauous septa in various parts can be seen, and
are apparently the ati opined remains of the
folds of the lining membiane A well-marked
membrane is sometimes seen running up fiom
the tendon of the tensor tympani to the roof
On microscopical examination the layers aic
atrophied, and the distinctive characteristics
cannot be made out The base of the stapes is
fixed to the oval window either by calcification
EAR MIDDLE EAR, CHRONIC NON-SUPPURATIVK DISEASE
515
or ossification of the ligamentous ring, or by
deposit of new-formed osseous substance upon
the inner surface of the footplate, and a com-
plete bony union of the wall of the oval window
may exist (Pohtzer)
The condition is thought by some to be due
to a trophic lesion, as, especially in the later
stages, little or no injection of the malloal vessels
takes place on efficient inflation , but this may
be due to the iact that the vesst It* share in the
atrophic process, or arc constricted The fact
that ganglion cells are touud in the lining mem-
brane suggest that some change 111 them may pos-
sibly interfere with nutrition Trophic causes,
however, will not account ten bony anchylosis
of the base of the stapes, a condition which
points to some irritative periostea! cause Thoma,
in his \voik on patholog}, describes an atrophic
catarrh in \\hich the mucous membianc becomes
thinner and atiophiud, and it must be allowed
that such a process will most icadily account
for the condition found
With icgaid to the sccoudaiy affection of the
luhyimth, nupaiiment of function may icsult
simply from disuse , but in some cases, at all
events, further changes must exist It may bo
that the atiopluc process is continued to the
cavity of the labyrinth with lesultmg decrease
of secretion of the mtra-labyi mthine fluids, the
pcnlymph in paiticulai
Some <as«s with symptoms closely resembling
those seen in this group have been found by
Toynbee, Politaci, l>c/old, and others to be duo
to a prmi.u y affect ion ot the labyimthmc bony
capsule, piodiicmf* anchylosis of the base of the
stapes, without an} pathological lesion of the
lining im*mbrane
tiymytomi and »SV/7w — The onset ot the deaf-
ness is so insidious that, as a rule, the patient
does not come toi treatment until the disease is
well advanced In some a slight hissing tinnitus
was present for some time before the deainess
was noticed , a giadual decicase of hearing in
one ear, usually the left, being un noticed 01
disiegaided until the other ear became seriously
affected, both eais then gradually becoming
worse In other cases the patient's friends ,uc
the Hist to notice the diminution in function
The tinnitus is often not distressing, the patient
getting absolutely used to it , in others it is one
of the most prominent features. When the
disease has advanced considerably in both oais
paracusis is a mai ked symptom The hearing
is usually worse during a cold. Occasionally
the disease appears to stop short, or to progress
very slowly, when the later stages are reached,
and complete stone deafness is never obseived
On inflation a very slight improvement in hear-
ing is produced, but soon disappears, and, as
before mentioned, little or no lesultmg injection
of the raalleal vessels can bo seen In some
the inflation may not bo felt in the eai,
although the diagnostic tube cleaily indicates
that it has been successful Attacks of tnic
auditory vertigo are not experienced The
Eustachian tube shows no signs of obstiuction,
but, on the eontiary, seems unusually patent,
the air entering very clearly and dryly On
examination the meatus is usually clear of ceru-
men — in fact, patients sometimes complain that
their ears seem dry. On looking at the mem-
brane the absence of gross changes is very
maiked } it often looks unusually bright, clear,
and thin, with little or no signs of depression
The membiano and malleus move freely with
Siegle's speculum The nose and naso-pharynx
in the majonty of cases appear perfectly
normal , sometimes the nose may appear diy,
tin* patient stating that a handkerchief is not
often necessaiy, and the lining membrane of
the naso-pharynx may appear thin, the lips of
the Kustachian tube standing out boldly, but it
is nevei diy and glazed There appears to be
no connection, as one would expect, between
so-called atrophic rhinitis and this disease.
Paleness of the soft pallet with a blush on each
sido is usually present (Urban Putchard)
lot/now — Thi
his is always extremely bad, no
treatment h.is any power, apparently, to check
its progress, the deafness goes fiom bad to
worse, but may stop short at some point,
absolute deafness ne\er resulting, the patient
being always able to hear something
Dtfif/no^it — The n^e and sex of the patient,
the insidious onset, the appearance of the mem-
biano, the absence of Eustachian obstruction,
freedom and dryncss of air-entry on inflation,
the slight improvement produced thereby, and
absence of any cause in the nose or naso-
phaiynv, sepaiate this fiom othei middle eai
diseases The tuning-fork, etc , will distinguish
it fiom internal, and in those cases in which
internal ear icsults are produced by the tunmg-
foik the piesence of paiaciiHis will give the clue
In cases of pumaiy disease oi the labyrinthine
capsule the pink lining membrane can be seen
through the membruna tympam
Tiuitment — As before stated, we have as yet
no treatment \\hich has any power to check the
disease when once it has started
The general health of the patient must be
put in the best possible condition The local
treatment is merely palliative, and even this
must be used with extreme caution 01 the patient
\\i\\ be made distinctly worse Occasional
eatheterisation with injection ot paroleme, or
inflation with the bag, especially if a few drops
of chloroform be previously introduced, produces
a slight amount of improvement, and is a com-
fort to the patient The chloride of ammonium
inhaler produces little or no benefit, except that
a tendency to colds is hey in check
Massage with Siegle's speculum m the
ordinary way must be very cautiously and
gently applied, as in the great majority of cases
it is distinctly detrimental • Too prolonged
516
EAR MIDDLE EAR, CHRONIC NON-SUPPURATIVE DISEASE
application of inflation or massage will produce
undue flaccidity of the membrane, and BO add
to the trouble.
At the Sixth International Congress of
Otology m 1899, Mink stated that he had
produced good effects by using Sieglo's speculum
m a modified way The membiane and the
malleus are first compressed by air, stopping
short of pain, before massage is applied, this
method, which aims at moving the base of the
stapes, has not received a fair trial.
With regard to operative mtra- tympanic
measures the general experience is that they are
contiadicted, but perhaps it is only fair to say
that those on the stapes and inner middle oar
wall are still on their trial With regard to
artificial aids in the extreme stage, lip-reading
lessons die of great -value, and may entirely
alter the patient's outlook on life Mechanical
aids are mainly useful for individual conversa-
tion , uhen obtaining one, all wrieticB should
be tried , as 11 mle, the oidinary speaking-tube
will be of the greatest service
C CHANGES PRODUCED u\ VARIATIONS IN
PRESSURE — Neyatiw PtPtwite in the Jynipa-
nttm — Concerning tint) little is known, but the
adoption of a separate class for it is warranted
by the deafness \\hich occur H in those who woik
under increased atmosphenc pressure, such as
deep-sea divers, and in those cases in which
deafness results as a result of chronic mechani-
cal obstruction of the tube, such us cicatucial
contraction, piessure of tumours, etc
It may bo stated, however, that it is difficult
to exclude the pievious forms of disease in these
cases, but, on the other hand, some of the
changes descnbcd as having resulted fiom a
chronic catairh may IKJ due to a long-continued
negative pressure
Causation — These aic of t\vo vine ties —
(a) Long-continued or often-repeated increase
of atmospheric pressure on the membrane
(6) Non-aeration of the middle ear, owing to —
(1) Mechanical occlusion of the tube by
cicatucial conti action, piessure of
tuniouis, etc.
(2) Nasal obstruction due to any cause,
especially when affecting the in-
ferior meatus, as this place is practi-
cally a continuation of the mouth
of the Eustachian tube.
(3) Paresis of the Eustachian muscles, as
occurs sometimes after diphtheria,
preventing by their inaction proper
aeration
Patkoloyy — Of this we have nothing but con-
jecture to go upon, but it can readily be con-
ceived that if air is prevented from entering the
middle ear by the atmospheric pressure from
•without, or by obstruction from within, a long-
continued or often-iepeatcd negative pressure m
the tympanum will produce a chronic dilatation
of the vessels of lthe lining membrane, with re-
sulting hypertiophy of the tissues and fixation
of the ossicular chain.
Symptoms and tiigwt — Those of the hyper-
trophic class, plus the obvious cause which
exists apart from catarrhal conditions.
Prognosis. — This will depend, firstly, whethei
the cause can be removed, and, secondly, if
removal is possible, on the results obtained by
subsequent aeration of the tympanum.
Duiynosis — As far as can be judged at present
this depends on middle car symptoms and signs
combined with an obvious cause of non-aeration
apart fiom catarrh
Treatment — In those working under inci eased
pressure care must be taken that there is no
hindrance to the entiy of air through the tube
In those cases in which non-aeration is due to
obstruction in the nose 01 naso pharynx, removal
of the cause, if possible, is indicated with subse-
quent aeration of the tympanum. With regard
to the removal of septal spurs or hypertrophied
tuibmals, a good rule to obseive is that they
should not be interfered with unless marked
blocking of the infenoi meatuH m present, or if
the passage of the Eustachian catheter is mter-
fcied \\ith When once the obstruction is re-
moved and subsequent aeration fails to produce
improvement, the question of mtra- tympanic
operations directed to removing the rigid OSNICU-
lar chain may be considered
J) CHANGES PRODUCED ii\ DEFICIENT BLOOD-
HUPPIA —Of this form little definite is known,
but cases aie met with in the later periods of
life when the clinical featuics — local and general
— suggest that the impairment of hearing may
be primarily dependent on inteiference with the
sound-conducting apparatus due to defective
nutrition of the soft structures of the middle
car The subjective symptoms are a gradual
detenoration of hearing power without tinnitus,
one ear being usually more affected than the
other, and varying with the general health and
condition of the patient On objective examina-
tion the membrane may be normal, but some-
times looks thinner and clearer than usual On
inflation the Eustachian tube is patent, but very
slight if any improvement results, the injection
of the malleal vessels after inflation being also
slight With the Siegle speculum the mem-
brane and malleus often move well, but as a
rule with no good effect When tested with the
tuning- foik it will be found that the internal
car is also impaired , \\\ some tho internal ear
impairment seems to predominate. Paracusis
and true auditory vertigo do not occur (In
some cases Gardiner Browne's test gives a normal
result, owing to the equal impairment of both
middle and internal cars , this sign, first pointed
out by Urban Pritchard, is of great value.)
With regard to the diagnosis of this condition,
it must be admitted that it is usually difficult,
even in the presence of marked evidence of
general arterial disease, to clearly separate these
EAR- MIDDLE EAR, CHRONIC NON-SUPPURATIVE DISEASE 517
cases from thobo of senile nerve deafness (vide ( "Gardiner Browne's" and "SchwabachV may
vol i. " Auditory Nerve ")• The treatment in 1 be of service as supplementary tests. These are
these cases is general , no local treatment is of I described on page 459.
any service. ' (6) By testing the range of tone hearing by
TBMTS FOR DIAGNOSING MIDDLE EAR FROM IN- ' means of tuning-forks, <Jal ton's whistle, Konig's
TBRKAii EAR DISEASE — These are chiefly of two ! rods, and musical instruments
varieties — ' Broadly speaking, in middle ear disease high
(a) By comparing the air and bone conduc- i tones aic heard better than low, and this may
turn in the patient, or with the normal, by means be earned to such an extent that the patient
of a medium C timing-fork , can hear a watch tick, and yet cannot hear
These tests vary in detail, but are based on thunder In comparing watch and voice hear-
the broad fact that in any external or middle mg, tho former is often heard, comparatively
ear disease bone conduction is gieatcr than air speaking, butter than the latter. In internal
in tho patient, and is increased \vhen compared < car disease high tones are usually lost Tumng-
witb the normal, the converse holding in internal forks, Galton's whistle, and occasionally musical
ear affections The tests known as " Wetor's " instruments, are the means used to determine
and " Rmne's " are those usually employed the^o points (see p 459)
INDEX
1 4
1 1
IAOL
PAHF
Bread
1 Biomocoll
(,
Bi iiLine
32
Breakbone Fevei
1 Bromotoim
G
Bruise^
32
Bieast
1 , Biomol
(,
Biuit
32
Bieastpang
1 Bromomania
6
Brunnei's < {lands
32
Breast Pump
1 Biomomenorihua
G
Brunoman System
32
Bioath
1 Biomopyim
7
Biussa
32
Breathing
3 Bromoi < in
7
Biygmus
32
Breathlessness
I Bioinum
7
Biyocytie
32
Bicech Piesentation
3 Bionchademtis
7
Bryoma
32
Bi cgrna
3 Biouchi, Diseases ot
7
Buboes
32
Biemci'b Blood Test
i .Bronchial (j lands
7
Bubonic Plague
^2
Brenzkateehinm 1. 1
3 Bionchitis
11
Bubonocele
32
Bi epho-
3 Bronchiectasis
2b
Bucco-
32
Bieweiics
3 Bionclne( tasis
31
Buchu Folia
32
Biicklayei'a Champ
3 Bronchiociisis
31
Buckthorn
33
Biickwoikei's Au.umia
3 Bionchiolcctasis
31
Bucnemia
33
Budes-les-Bains
3 Bionchiohtis
31
Jiudd's (Juihosis
33
Budge of All.ui
3 Biourhiospasm
31
Bude
33
Bridge Work
3 ' liiouclntis
U
Bufty Coat
33
Bughtoj)
) { Bionchitis, (lapillaiy
n
Bug, H.uvest
33
Blight's piseasu
3 Bionchotele
31
Buhl's Disease
33
Binn«of Pehis
3 lUonchohth
i 1 Bust's Method ot Ai tihcial
Bnquet's Syndiome
3 Bionchophony
31 Hespnation
33
Biittleness of the Nails
} Bi onchophthisis
31
Bulam F«'\ci
33
Broad Ligament, Diseases
J iionchoplein isy
31
Bulb
33
of
3 Bionchopneumonia
31
Bulbai Paialysis
33
Bio, id bent's Law
"> Bionchorih<igifi
31
Bulg.ma
33
Broadhent'h Sign
r> BiomhoiiliUM
31
Bulimia
33
Broca's Convolution
") liionchohcop}
Jl
Bulla
33
Brodie's Absceub
B , Bionehotome
31
Bullei's Shield
33
Broiling
5 | Bronchotomy
31
Bullet \\ oundH
33
Brom-
5 Bioncho-\cmculai Bieatli
Bulpiss
33
Broma
r) ing
U
Bunganis
33
Biomal llydiate
*) Bionxing of Skin
31
Bunge's \A\\\
33
Broinalbunnn
5 | Bioom Tops
31
Bunion
33
Biomatology
B Biophy'b Opeiation
31
Buphthalmus
33
Bromatoxibin
r> Bioth
31
Buid<ich'u (Column
33
Brombidrobis
5 Bronssaiuism
32
Buidwan Fovei
33
Bromide
5 Brow Ague
32
Bui gundy Pitch
33
Bromidia
5 Bicm O.ises
32
litinal-Places
33
Bromidin
5 Broun Atroj)hy
32
Buikmg
34
Bromidiosin
G BiONvn intimation
32
Buimesc Ring\\oim
34
Bromine
G BrowniHm
32
Buineft's Fluid
34
Bromiodofoini
6 i Biown-Scquard's Epilepsy
32
Bui us and Scalds
34
Bromipm
G , Brown-Sequaid's Paralysis
32
Bums, Diametei of
39
Brornism
6 j Biuch, Mcmbiane of
32
Buiqiiism .
39
520
INDEX
PAI.K
lAUfc
PAfl*
Burstc, Injuries and Dis-
Caisson Disease
46
Candela
50
eases of
39
Cajuput Oil
46
Candles
50
Burmnie Acid
43
Calabar Bean
46
Cane Sugar
50
Bursitis
43
Calamme
46
Camtics
50
Bushmen
13
Calamus Sciiptonus
46
Cannabis Indica
50
Bussorah Boil
43
Cnlcaneo-Cavus
46
Cannea
50
Butane
43
Calcaneum
46
Canneb
50
Butcher's Pemphigus
43
Calcaieous Concretions
46
Cannibalism
50
Buteoo Semina
43
Calcaicous Degeneration
47
Cannula
50
Butter
43
Calcanne Fissure
47
Canoi
50
Butter Bacillus
13
Calcification .
47
Canquom's Paste
50
Butterfly Lupus
43
Calcium <md its Salts
47
Canthandes
50
Butterfly Operation
43
Calculus
47
Canthoplasty
51
Butterfly Pcsbary
43
Calcutta Foci
48
Caoutchouc
51
Buttermilk
43
Caldanum
48
Capacity
51
Butter of Antimou}
43
Caldas da llamh.i
48
Capo Town
51
Buttocks
43
Caldas-de-(iere/
48
Capillaucs, Diseases of
51
Button
43
Caldos-de-M out I my
48
Capillary Bronchitis
53
Butyl Alcohol
Butyl Chloial Hydras
43
43
Caledonia SpnngH
Calefacient
48
48
Capital, Life
Capots
53
53
Butylene
44
Calendar, Obstetru
48
Capn
33
Butyphus
44
Calenture
48
Capric Acid
33
Butyric Acid
44
Calf-Lymph
48
Capsiei Ftuctus
53
Butyrometei
14
Calgaiy
48
(Japsule, Internal
53
Buxine
44
Calico-Dye IN
48
Capsules
53
Buxton
44
Call torn 1,1
48
Capsnlitis
33
Bynin
14
Calliper-! 'ompasscs
48
Capbulotomj
53
Bynol
44
C.illirrhoe
48
Caput
53
Byres
44
CcilliHthcnics
48
Caput Medusa)
53
Byrolin
44
Callositas
48
Caput Succcdancum
53
Byssmosis
44
Callus
48
C*arangidfi>
53
Calomel
48
Caiates
53
Cac- and Caco
44
Caloi Moid.i\
48
Caraway Fruit
54
Cacao Buttei
14
('alone
48
Caibahte
54
Caccagogue
44
Calorigen
18
(Carbamide
54
Cachets
44
Calotiopis
48
Carba/otic Acid
34
Cachoxia
44
Calumbiu Radix
48
Caibidc
54
Caehexia African a
45
Caharia
(9
1'aibo ,
54
Caehexia Satunnn<t
45
Cahitics
49
Caibohydiates
54
Cachexia Strimnprua
45
CaK
49
Carbohydratuna
")4
Cacodyl
43
Cambodia
49
Carbolic Acid
54
Cacoethcs
45
Cdineron's Septic Tank
49
Carboluria
55
Cacogunesis
45
(Uinisole
49
Cailx>n Bisulphide
35
Caeopathia
45
Camp Fc\vi
49
CailMimc Acid
55
Cacosmia
4r>
Cumphene
49
Carbonic Oxide
35
( tacothyima
Cadaveric Rigidit\
43
43
I 'amphora
Campy I on hat his
49
49
Carlxniyl Chloride
Carbuncle
55
55
Cadavcimo
43
Canada
49
Catburetted Hydiogen
55
Cade, Oil of
15
Canal Boats
49
Carcinoma
55
Cadonal>bi.i
ifi
Canal, ("locnict's
49
Carcmosis
55
Cadmium
46
Canal, Genital
49
Cardamomi Semina .
55
Caduca
Caduca Passio
46
46
('anal, Havoisian
Canahciili
49
40
Cat den's Amputation
Cardia
55
55
Cawitas
46
Canalisation
49
Cardiac
55
C,ccum
46
Canal of Nuok
49
Cardialgia
55
Cwnwsthcbis
46
Canals, Semiciicular
49
Cardiocele
55
Cwsalpima
46
(Canary Islands
49
CardiocentesiH
55
Ciesaieun Section
46
(\mcellous
50
(1ardiodynia
55
Ccesiuiu r
to
C'ancet
50
(Cardiogram
55
Caffeamc Acid
(6
Canchasmus
50
Cardiohth
55
Caflfema .
46
Cancrom
30
Cardiolybis
55
Cagot .
46
Cancrum Ons
50
Cardiomalacia
55
INDEX
521
i At.* r
M t
PAC.V
Cardiometer .
56
Cataptosiu
60
taphalic
79
Cardioptosis
56
Cataract
60
Jephahne
79
Cardiorrhexis
56
Catarrh
71
Cephalitis
79
Cardo .
56
Catarrhe Sec (Laennec)
71
>phalo-
79
"Carferal"
36
Catarrhns </Estivus
71
Jephalocele
79
Caries .
56
Catarrhus Commums
71
'ephalodyma
79
Canes Sicca
56
Catarrhus Epidemicus
71
/ephalonieter
79
Cannated
56
Catairhus Fennus
71
>phalopagua
79
(Carlsbad
56
CatastasiH
71
^ephalopinc
79
Carminatives
56
Catatoiny
71
Jcphalothoi acopagus
79
Ccirmferrin
r>6
Catchment Are.i
71
'. 'cphalotorny
79
Carmferrol
36
Catechu
71
(1eph«ilotnps>r
79
Carmfication
56
Catcrpill.ii Rash
71
*-*
Com
79
Carnin
")6
Catgut
71
Derasm
79
Camivora
-i6
Cathsercsis
71
Cerastes
79
Carnochan's Oper<ttiou
->6
Cathartu s
71
Cerates
79
Carotid Artery
56
Cathelcitrotonuu
71
Certouiothis
79
Carotin
5o
Cathotcnsation
72
Cereals
79
Carpal Bones
56
Cathctei Fo\ui
72
Ceiebcllum
79
Carphology
56
Catheteis, Uses and Dangers
7 'J
Cerebiation
79
Carpo-Pedal Spasm
56
Cathetometer
7rj
Ceiebnn
79
Carpus
56
Cathode
75
( 'erebntis
79
Carrageen
56
Cattivo M.Uo
75
Cerebrosis
79
Carrotraca
56
Cattle
75
Cerebro-Spinal Fevei
79
Oarreau
56 Cattle Plague
76
Cerebrum
80
Carrion's Disease
56
Cauda Equina
76
Ceresole Keale
80
Carron Oil
56
Caudate Nucleus
76
Cerium
80
C<irrotin
56
Caul
76
Cerolin
80
Carrots
56
Cauliflowt'i
76
Cerotic Aeid
80
Cartilage
56
C.uihalgia
76
Ceitification
80
Carni Fiuctus
57
Can sis
76
Cerumen
80
Caruncle
57
(1auhtics
76
(1ervic,il
80
CarimculcC Mjrtiformes
57
(yiintercts
76
C'er\i\
80
Cams
r>7
Cautery
76
Cemv Uten
80
Caivol
17
Ca\eimtis
77
Cci^ I
80
Caryoqnusis
Caryophyllum
57
57
Cavcinous Bie.ithmg
Cavoinous Sinus
77
77
Cesspools
Cestodes
80
80
Carynplasm
57
Ca^ itics
77
Cetaceum
80
Casaiuicciola
57
C.iyoi Fly
77
Ce^adilla
80
Cascara Sagrada
57
Cebocephalus
77
Ceylon S<jre Mouth
80
Cascanllce Coitex
57
(yelenna
77
Cham
80
Casoation
57
Celery
77
Chala/ion
80
Casein
57
( 'olibacy
7S
(1hahcosis
81
Cassitc Pulpa
57
Collais
78
Chalk
81
Castcllamaro
58
Cellotiopin
7b
Challes
81
Castollamari di Stabia
58
(His
78
Chalybeate Waters
81
Castor
58
Celluhtis
78
Chamtecephaly
81
Castor Oil
~>8
('ulluloul
78
Chamonnle
81
Castration
58
Cellulose
78
Champetiei de Kibes' Hag
81
Casts
r>8
( 'elosomus
78
Champignon
81
Cata-
58
(Vinent
78
Chancery
81
Catabohsm
58
Conientoniu
78
Chancre
81
Catabythisnius
Catalase
58
58
Cenietom's
Cen.usthcsis
78
78
Chanci old
( 'hange of Life
81
81
Catalepsy
58
Census
7.s
Chaps
81
Catalysis
60
Centiiiietie
78
Chaias
SI
Catamema
60
Centipedes
78
Cluirboii
81
Catapasm
60
Centres
78
Charcoal
81
Cataphasia
Cataphoresis
60
60
Contnhige
Centrosome
78
7i
Charcftt's Disease
(1harcot-Loyden Crystals
81
81
Cataplasm
Cataplexy
60
60
Cephalalgia
( Vphalhsematoina
71
7«
Charpie
JPhart .
81
81
522
INDEX
i
f'AOE
PAdE
FAUE
Chaita .
81
Chlorahsni
1 08
Choreomama
138
Chartula
81
Chlorate of Potash
108
Chonoma
138
Chasnms
81
Chloretone
108
Chorion
138
Chatel-Guyon
81
Chloric Kthci
108
Chorion-Epithehoma
138
Chaudfontame
81
Chloride of Kthyl
108
Choroid, Dibcabos of
138
Chaulmoogia Oil
81
Clvlondes
108
Choroideremia
146
Cheek, Fissure of
81
Chloi mated Lime
108
Choioiditib
146
Cheese
82
Chloi mated Soda
108
Choi oido-Cyclitis
H6
Choilo-
82
Chlorine
108
Choioido-lntis
146
Choir-
82
( Uilormism
109
( "hoi oido-I tetmitis
146'
Cheiropompholyx
Cheloid
82
82
Chloiobrom
Chloioduio
109
109
Choioid Plexiib
Chiom-
146
146
Chelomsomus
82
Chloiofoim
109
Chiomatm
146
Chelsea Pensionei
83
Chloioma
109
Chromatolybis
146
(Cheltenham
83
Chloiosis
109
Chiomatopbia .
146
Chemical Trades
83
Chloios
114
Chromatuna
146
Chemosis
83
Chlorozoni1
114
" Chi omo Holes"
146
Chomotaxis
8S
( hloiyl
114
Chroimdrosib
146
Chenopodmm
8 J
( 1hocolate
114
Chiomibiu
146
Cheiry Laurel
83
Choke Damp
114
Chromium
146
Chest
83
Choked DIM-
114
I'hioinoc^ tometer
146
Chest, Clinical Jirv estiva-
Choking
114
Chiomogens
146
tion
Chest, Defoimitic, of
Chcbt, Injuries of
(-host Wall, Affections ot
83
88
90
94
Chol.emia
( 'holangio&tomy
Chol.mgiotomy
111
114
115
115
( 1hiomophanes
Chiomophile Subbtince
Clnomopioteid
Chiomopsia
146
146
140
140
Chcyne - Stokes' llcspn .1-
Chol.ingiti*)
Chrumosoinc.s
147
tion
97
Cholc-
1 1 5
(1hiomc
147
Chuuciano
Chian Turpentine
Chiari's Salpmgitis
98
98
98
Cholecjhtoi tomy
Cholccystendysis
( 1holecystenteiostomy
115
115
115
C'inonoliopic
('hrysaiolnnum
Chiysophan
147
147
147
Chiasma
Chicken
Chicken-Breast
98
98
98
( Jholecystitis
Cholocyslostomy
Cholecybtotomy
115
115
115
( 'hthononobology
( 'hthonophagia
Chin i us
147
147
147
Chicken- 1 N>\
Chick-Pea
98
98
(1holedochotomy
Cholelithiasis
IT)
in
Chvostek's Symptom
Chylangioina *
147
147
Chijygoo
98
C'holei a, Asiatic
115
Ch\le
147
Chilblains
Child
98
98
Choleia, Epidemic
( 'liolcia Inf.mtum
115
125
Chylecchybib
Chylocele
' 147
147
Childbed
Childbirth
98
98
Choi ei a Moibus
Choleia Nostras
125
125
Chylodcnna
147
147
Child-Ci owing
Childhood
/1U.1 .1- _.
98
98
( 'holcrme
( 'liolcbteatoma
128
128
Chylothoiax
(liylous Ascites
147
147
^nuuien
98
128
1 M
(Children, Development
Cholesteune
128
Chyme
147
and Clmic«il Evaimna-
Cholcstoiitib
129
Ch} mosm
147
tion
98
( 1hohc Acid
129
Cilnsitome
147
Chill
107
('holme
129
C'leatnces
147
Chilli? Pabte
107
( 'hologen
129
Cicchocinck
150
Chimneys
Chimney Sweep's Cancel
107
107
Cholopoiesis
Cholui 1.1
129
129
Cigarettes
Cilia
151
151
Chin-Cough
Chinolme
107
107
Choiidi-
(1hondro-Aithritis
129
129
Ciliaiy Hody
Cillosib
151
151
Chmobol
Chionablepbia
Chirapsy
107
107
107
( 'hondi odystrophia Fa»t-
ahs
Chondioiiici
129
129
Cimex
Cmucifugw lihizoma
Cimiez .
151
151
151
Chiretta
107
C'hoi>art's Operation
129
Cinchona
151
Chiropodist
107
Choi <la
129
Cmchoninc
151
Chloasma *
108
Choi dee
129
Cmchonibm
151
Chlor-
Chloral Hydrate
Chloralamide «
108
108
108
Chorditis
Chordoma
Chorea
129
129
129
Cinder-Sifting Movement
Cinematograph
Cmcsitherapy
151
151
151
INDEX
523
PACr*
IA( h
PAdk
Cinnabar
151 Clinic
1 67 ( 'ojiiui us Cerebralis
173
C/mnamic Acid
151 Clinical
167 Cottee
173
Cinnamon
151 Chnoccphaly
167 CJoffce-Ciround Vomiting .
173
Cum
152 Chnodactyhsm
167 (Jofhn-Birth
173
Circulate
152 , Clmoscopc
167 Commsm
173
Circle of Haller
152 (Nitons
1 67 C'ognac
173
Circle of Mascagne
Circle of Willw
152 Cloaca
152 ' Clomc
167 Cog \\heel Respiration
167 Cohnhcun'ss Thorny
173
173
Circular Insanity
'Circulation
152 Clonus
152 Cloquot's Henna
167 Coif
168 Coihns of Coid
173
173
Circumcision
152 Closet
168 (1oiii-Soiind
173
Cn cumcliibion
154 Clothing
168 Coitus
173
C n cumd notion
154 Clouds
16^ Coke
173
Cnunnferences
151 Cloudy Swelling
108 Cola
173
Cncumflex Neive
154 Clove Hitch
168 Colchicinc
173
Circumstantial Evidence
154 Cloves
Ki8 (^olclucum
173
Circuin val late
151 ( Howmsm
168 (1old
174
Cirihosis
155 Clnb-Foot
168 Cold Cieam
174
Cirsocele
15") Club-Hand
168 < 'old Pack
174
Cnsoid Ancurysm
155 Clubtan^
168 Cold Spots
174
Cirsomphalos
lr>5 ('lupfaThiyssi
168 Colectomy
174
Cirhophthalmm
1")5 ' Clystei
168 (Joleoptosis
174
CiiBotomy
155 • Cnemial
168 ( \>leoi rhcxih
174
Cissampellos
155 Cnesis
168 ( Joleostegnobis
174
Cisteirw
15") ( 'nulosis
168 (Vilry'h Fluid
174
Citaim
155 ' < 'oagulation
168 Colic
174
Citnc At id
1 55 ( toagul ition Neciowts
108 (1olica Pictonum
176
Citrine Ointment
155 (1oai;ulins
1 68 Colitis
176
Cittosis
1 "M ( Joal lias
lf>8 Collagen
176
Civet
1 55 Coahiie
169 Collapse
176
Civiale's Method of Uie-
(*cul-Mmeifs Luii^
1 69 (1ollcs' Fractuie
177
thiotomy
1 5.") ( 1oaptation
169 Colics' Law
177
Civil Incapacity
15") Ciui datum
169 ( 'Ol ley 's ( )peration
177
Civilisation
15rt Coat
1G() Collit'i's BumchiliH
177
Cmta\ecchia
15rt (4uKilt
109 Colliq native Neciosis
177
CUdotfcm Dichotoma
1 ob ( 'obi is
169 (^ollodia
177
Clairvoyance
H(> (1oca
169 (bllodum
177
Clamp
1 ")f> ( \H am.i
169 Colloid Degeneration
177
Clap
15fi Cocaine
160 Colloid Mil HUH
177
( 'lapotage
15() Coc.uiHs<ition, Spinal
171 Colloid, Stvptic
177
Claike'b (Column
15G (1ocudiosis
171 ( Jollunai la
177
Clark's Piocess
l.">7 Coccidium
171 Collutoimm
177
Claudication
157 Coccnlus Indicus
171 Collyna
177
( 'laiiHtromania
157 , (1occus
171 Coloboma
177
Claubtiophobia
Claviceps Purpmed
Clavicle
157 Coccjalujia
1 57 Ooccynci'toiry
157 Coccygodynia
171 (1olocynth
171 Colon, Diseases ol
171 Colonisation
177
177
187
Claviib
157 ' Coccyv
172 Colopexia
187
Cldvns Hystencns
Claw Hand
157 Cochin (-hina Uleei
157 (V-hineal
172 ! Coloptobis
172 , Coloi.ulo
187
187
Cleft
157 (Cochlea
172 Colonmetei
187
Cleido-
157 i^oohleaie
172 (Jolostomy
187
Cleidotomy
Cleptomama
Clevedon
157 (1ock's Opeiation
157 Cocleh
157 ' Cocoa
172 Colostium
172 Colotomy
172 ("olour- Blindness
187
187
190
Clifton
157 Cocoon Silk
17J , Colour- Vision
190
Climacteric
157 j Codannnc
172 ( 'olounng Matters
199
Climacteric Insanity
Climate and Acclimatisa-
157 Codema
Cod-In er Oil
172 , (kilp- 01 Colpo-
172 (^Ipectomy
199
199
tion .
161 Co)lo- 01 Cojlio-
173 Colpitis
199
Climatology
Cliniatna
167 Cccnudelplms
167 ("oenti'Btliosis
173 Colpoclcisib
173 •(1oljK>cystotomy
199
200
524
INDEX
TAOF
PAQK
Colpohyperplasia Cystica
Colporrhaphy .
200
200
Confusional Insanity
Congelation
203
203
Cord
Cordentery
226
226
Colpotomy
Colubrme
200
200
Congenital
Conger
203
203
Core-
Conaudn Fructus .
226
227
Columbia, British
200
Congestion
203
Conum
227
Columna
200
Congo Sickness
203
Corn
227
Cohtyn Bay
200
Conhydnna
203
Cornea
227
Coma
200
Conical Coniea
203
Cornet Player's Emphy-
Coma Vigil
200
Conidia
203
sema
242
Combined Degeneration
Conine
203 j Cornflour
242**
of the Cord
200
Comum
203 ; Cornu .
242
Combustion, Spontaneous
Comedo
200
200
Conjugate 01 Conjugata
Conjugate Deviation
203 ' Cornutma
203 Corona liadiata
243
243
Comes
200
Conjunctua, Diseases of
203
Coronal Suture
243
Comitiahs Mot bus
201
Conjunctivitis
215
Coronary Arteries
243
Comma Bacillus
201
Connective Tissues
2 IT) i Coroner
243
Comma Tract of Schtilt&c
201
Consanguinity
215 | Corpora
243
Commensahsm
201
Consciousness
215 Corporc Conduphcato
243
Comminution
201
Consensual
*215 , Corpulence
243
Commissuial Aphasia
201
Consent
215 Corpus
243
Commissure
201
Consen ancy 83 stem
215 , Corpuscle
243
Common Lodging-Houses
201
Consents
215 Coiiigan's Button
243
Commotio
201
Consomme
'215 Corrigens
243
Communicated Insanity
201
Consonants
21")
Corrosive Sublimate
243
Compatibility
201
Consternatio
215
Corsets
243
Compensation
201
Constipation
•215 Cortex
243
Complement
201
Constituens
210 Corti, Organ of
243
Complemental An
201
Constitution
219 Corybantism
243
Complexion
201
Constitutional Diseases
219 i Coryza
243
Complication
201
( 'onstrictors
2l() Cosumuiu
243
Component
201
Consultation
21') (Cosmetics
243
Composite Portraitme
201
Consumption
220 ! Costa- or Costo-
24.)
Compositoi's Disease
201
( 'ontagion
220 Coster's Paste
244
Compos Mentis
201
Continued Fe\ei
*220 CostiveiH'Hs
244
Compress
201
Contracted Kidne\
2'20 Cotannna
244
Compressed- Air Disease
201
Con t met ion
220 Coto Cortex
244
Compression
201
Con trac tin e
220 Cottenll's Operation .
244
Compression of the Biain
•201
Contraindication
220 Cotton Root Bark
' 244
Concato's Disease
201
Contie-Coup
220 Cotton- Wool
244
Concealment of Bnth
201
Controxeville
220 (Jotugno's Disease
244
Conception
201
Control
220
Cotyledon
244
Concha
202
Control Expeinnent
220
Cotyloid
244
Conclmation
202
Contusion*
220
Couch Glass
244
Concomitant Stiabismus
202
Conus Artenosus
223
Couchmii,
244
Concrescence
202
Conns MedullaiiH
223
Cough
244
Concretions
20'2
Convalescence
223
Coulomb
246
Concussion
202
Convallaria Majalis
223
Counter Irritation
246
Condal Water
202
Convergence
223 ! Counter Opening
246
Condensed Milk
20'2
Convolutions of the Brain
223 Country Fever
246
Condensei
202
Convulsions
223
Coup-de-Soleil
246
Condor's Process
•202
Convulsions, Infantile
223
"Courses"
246
Condiments
202
Convulsive Tic
225 Court Evidence
246
Condom
202
Cooking
226 Couivoisier's La\\
246
Conduct
202
Coopei, Astle}
226
Couveuse
246
Condurango
202
Co-ordination
226
Cowls
247
Condyle
•202
Copaiba
226
Cowpentis
247
Condyloma
20'2
Copper
226
Cowper's (i lands
•247
Condy's Fluid
202
Copra- 01 Copro-
226
Cow pox
247
Confcctio *
202
Cor
226
Cowsheds
247
Confinement
202
Coraco-
226
Cow's Milk
247
Confluent
•202
Coracoid Process
220
Coxalgia
247
Confusion ,
202.
Coral Calculi
226
Coxa Vara
247
INDEX
525
PAI,t
PAGE
PAGI
Coxitis
247 Cry
254
Cyclone
262
Cracked-Pot Sound
247 Crytesthesia
255
Cyclopia
262
("ramp
247 Crymoses
255
Cycloplegia
262
Crania Progenea
247 Crymotheiapy
255
Cyclotia
262
Cranial Neivcs
247 Cryoscopy
255
Cyesis
263
Cranio-
247 Crypt
257
Cylmdiom i
263
Cranium
248 Crypto-
257
Cyllosomus
263
Cranium Progemurn
248 ( Cryptogenetic Septiccemia
257
('ymene
263
(Jransac
248 Cryptomeuorrhoia
257
( 'ynanche
263
'•(Crapulence
248 Cryptophthalmus
257
('yiianthropia
263
Crasis
248 Cryptxmhism
257
Cynic Hijasm
263
Crassamentum
248 Crystallma
257 \ Cynobcv Hebetis
263
Cratomama
248 Crystalline Lens
257 ' Cynocephalus
263
Craw-craw
248 Crystal Pox
257 Cynolyssu
263
(/ream
248 Ciystals
257 ' (Jynorexia
263
Cream of Tartar
248 Cuban Itch
257 i Cyotoua
263
Cieamery
218 Cubeb,i« Fmctus
2^7
(/ypliosm
263
Croat
248 Cubital
258
Cypius Fc\ei
263
Cieatm
218 Cuca
258
(Jyitometer
263
Crede Method
248 ' Ciumhitic Semma
258
Cyst
263
Cieduhtas
218 ' Cuk-v
258
(^yst- 01 Cjsto-
264
Creeping Eruption
248 ( 'uliueide
258
C'ystadenoma
264
" Creeps "
248 ' Cultnation
258
Cystalgia
264
Cremastei
248 Ciiltme
2->8
Cystatrophy
264
Cremation
248 Cumin Flint
258
( 'ystauchciiotomy
264
Cremometer
248 Cumulative Action
258
C}stau\e
264
Ciemora
249 Cuneate Lobe
258
( !ystectasy
264
Cioolm
249 ( 'unrolrysterectomy
258
('ysteotomy
264
Cioosote
249 ( 'upping
258
( 'ystencephalus
264
Creosotal
249 Cupping oi the Optu
Cvstu
264
( )repitiih
219 Disc
218 ' Cystu-ercus Bovis
264
descent Bodies
249 Cupium
258
Cysticeicus ( ellulosoj
264
Cresol
249 Cui.na
258
('ysticcrcus Tenuicollis
264
Ciest
219 CuidSoaj)
258
( 'ystm
264
Crcsyl
249 Cino
2")8
Cystitis
264
Cretd,
219 Curettage
259
Cystocele
264
Cictan Fever
249 Cunent
261
( 1y»todynia
264
Cietinism
249 Cursehmann's Spnala
261
Cystoenteroecle
264
Cieyat
252 Curtilage
261
(Jystohthiasis
264
( Cribriform
252 Cmvature
261
Cystoma
264
Cnco-
252 , Curve
261
Cystoptosis
264
Ciunmal Responsibility
Criminology
CMSIH
2*32 CUM o's Speculum
203 Cusp
253 ( Juspai i«o Coi tc\
261
261
261
Cystopyehtis
Cystoiihexis
( 1ystos( hisis
264
264
264
Crispation
254 Cusso
261
Clystoscope
264
Cnsta
254 Custard
261
( Jystotomy
267
Crocus
2P)4 Cut-Tin oat
261
( Jytisme
267
Croft Spa
254 Cutaneous Diseases
261
Cyto-
267
Crombie's Molar Ulcei
251 ditiile
261
( lytodiagnosis
267
Cross Birth
25 1 Cut^
261
Cytolysnis
269
Ciosscd
254 Cuviei, Dui't ot
261
(Jytoryetes VanoltU
269
Crotalidao
2*>4 i Cyan- or Cyano-
261
CytotoMiies
269
Crotchet
254 Cyanatc
261
Cyto/oa
269
Croton Oil
254 Cyanic Ac-id
261
Croup
254 Cyanide
261
Daboia
269
Crowborough
Crowning
Crura
2.">4 Cyanogen
254 Cyanosis
254 Cycle
261
262
262
Daciy-
Dacryoademtis
I Xurryoblenoi rhaia
269
269
269
Crus
254 Cyclic Albummuiia
262
DacifOcystitis
269
Crusta
254 Cycling
262
Dacryohth
269
Crutch
254 Cyclitis
262
Dacryoma
269
Cruveilhier's Palsy
254 Cyclocephalus
262
•Dacryon ,
269
INDEX
l'A( t
1 VII- (
Dacryops
269
Defectus
278 Depletion
303
Dacryosolemtw
269
Defei vescence
278 Depopulation
303
Dacryosynnx
269
Dcfibi ination
278 Deposit
303
Dactyhtis
269
Defloiation
278 Deprebsio
303
Dactylolysis
Daetylotheca
269
269
Deformities
Degeneracy
278 Depression
296 Depressor Nerve
303
303
Doemonomama
270
Dcgenotates
296 Deradelphus
303
Dairies
Dalby's Caimmative
270
270
Dogciiciation
Degeneration, Nissl's
296 Dcrbyshuo Neck
296 Dercum's Disease
303
303
Daltonism
270
Degeneration, Reaction of
296 Derencephalus
303*
Damiana
270
Deglutition
296 Den\atives
303
Damp
270
Dchisccnce
296 Derniacentoi Ameiicanus
304
Dance, St Vitus'
270
Dehumamsation
296 Dcrmam^iabis Lineans
Dancer's Ciamp
270
Deiters' Nucleus
297 Migians
304
Dancing Mama
270
Dejection
297 Derm,inyssus Avmm
304
Dandelion
270
Delayed La bom
297 Deimatalgia
304
Dandrift
270
Delhi Boil
297 Doimatauxc
304
Dandy Fevei
270
Dehgation
2()7 ! Dermatm
304
Daneverd
270
Dchqumm Annul
297 Deimatitis
304
Dangoious Trades
270
Deliramentum
297 Deimatitis Kxfolmtiva
Daphne Mexeroum
270
Deluiants
297 Neonatouim
304
Daner's Disease
Darjilmg
270
270
Delirious Mania
Delirium
2')7 Deimatitis Herpetif 01 mis
2U8 Dermatitis Repens
304
308
Dartos
270
Delirium Grandiosum
2()S Deimatitis Tiaumatica i-t
Dartre
270
Deli 11 urn Mussitans
29S Vi'iienata
308
Darwmiamsm
270
Dehnum Tiemens
298 Deimatitis Ti.iumatica in
Dasytes
270
Delneiy
299 Coal-Mmeis
311
Date of Dehveiy
270
I >elphme
29<) Deimatobu
316
Datura Folia
270
Delta
29(J Deimatol
316
Datura) Semma
270
Deltoid Muscle
2()() Dei matology
317
Datura Stramonium
271
DC Lunatic o Inquiiendo
2()() Deimatol) HIS
317
Daturmo
271
Delusional Insanity
2D() J )oi matomvcosis
317
Daughsh's Bread
Davamea Madagascanensis
271
271
Delusions
Dementia
299 Deiuiatomyositw
300 Deimatosos
317
317
Davos Plat/
271
Dcmissio Animi
300 1 )ei m.itosp«ismus
317
Dax
271
Demme's Kw ilh
300 Dcimogiaphia t
317
Day Blindness
Daymare
Dcafmutism
271
271
271
Dcmodcx Folliciiloiuin
Demogr.iphy
Demonomauia
300 Dei moid OystsaiidTumqms 317
300 Dennoidcttomy »317
JOO Dnmol 317
Deafness
27f>
Demorphmisation
300 Deimotvlosis
317
Death
27 r>
Demulcents
300 DerodidVmus
317
Death-Rite
275
Dendntes
300 Deroim-lus
317
Dcath-Rattle
275
Dendntu Ulcei
300 | Des,tlination
317
Death, Signs of
27.;
Dengue
300 Desault's Splint
317
Death Struggle
276
I )emdation
302 i Descemet's Membrane
317
Debility
276
Demtiihcation
303 Deseensus
317
Decapitation
276
Denman's Spontaneous
Desiccation
317
Decapsulation, Renal
276
E\olution
303 1 )csma- 01 Desmo
317
Dechery Cautery
276
Dental Canes
303 ' Desnif)-Bacteria
317
Dechloi mation
276
Dental Necrosis
303 I )esq uamation
318
Decidua
Dociduoma Malignum
278
278
Dentals
Dentate Nucleus
303 i Dcsquamativc Nephntis
303 Destructoi
318
318
Declaration, Dying
278
Dentifrice
303 Det,ichment of Placenta
318
Declination
278
Dcntigcrous Cyst
303 Detachment of Retina
318
Decline of the Birth-Rate
278
Dentine
303 Detontio
318
Dococta .
278
Dentistry, Mechanical
303 Detoi gents
318
Decollator
278
Dentition
303 Determination
318
Decomposition
278
Denture
303 Determination of Sex
318
Decubitus c
278
Deobstruent
303 Detrusor
318
Decussation
278
Deodorants
303 Deutcro-
318
Defalcation
278
Deodorising Liquid
303 Deutero-Albumoso
318
Defectio Aninn
278,, Depilatoncs
303 Dcuteropathic Insanity
318
INDEX
527
PAOI
PA«,K
»A«i»
Deutoro-Proteoses
318
Dichirus
350
Diplopia
400
Deutoplasm .
318
Dichloracetic Acid
350
Diplosomus
401
Development
Developmental Idiocy
Developmental Insanities
Developmental Method
318
318
318
318
Dichotomy
Dicioccohnm Lanceolatum
Dichroism
Dichromatopsia
350
350
350
Diplotoiatology
Diprosopns
Dipsesis
I Dipsomania
401
401
401
401
Deviation
319
Dicrotism
350
Dipsophol.ia
403
Devonshire Colic
310
Dictyoid
350
Dipteia
403
Devoto's Method
319 . Didactyhsm
350
Dipns
403
Dew
319 Didelphys
350
Dipygns
403
Dcxiocardia
Dextrin
319
319
Didot's Opci.ition
Didyrnm
350
330
Dipyhdium Caninum
Duect Action
403
403
Dextrose
319
Dienceph don
350
Direct Tratts
403
Dhobie Itch
319
Diet
350
Dncctoi
Diabetes
319
Dietan
365
Dirihmns
403
Diabetes Insipidus
319
Dictctiis
365 Dnt-K«iting
403
Diabetes Melhtus
321
Dieth)l
365
DIS.K thai ids
103
Diacetic Acid
337
Diethylamme
365
1 )isassinul ition
403
Diacctmia
337
Dietl's Ciiws
361)
J hsassociation
403
I hacety 1 moi ph nu >
337
Dieulafoy's Aspnatoi
36")
DlSL
403
Diachalasina
337
Diftusion
363
Dischaige
404
Diachoresis
337
Digalhc Acid
365
I hscission
404
Ihachnsis
337
Digestion and Metabolism
365
Disdmation
404
Diachylon
337
Digit, 1 1
383
Disci etc
404
lhadei m
337
Digitali'in
383
Disc romatopsia
404
Durresis
337
Digitalis
383
Discus
404
Diagnosis
337
1 hglossia
384
Diseutients
404
Diagonal Conjugate
3 '37
Dihydiu Alcohols
384
DiHMSC
404
Dial in ic Acid
337
Dilatation
'584
Disiniection
405
Dialysis
337
Dilatoi
184
1 >islo( ation
413
Di.dyscd lion
337
Diletanus
385
Ihsomata
413
Diameter
°»38
Dill Flint
385
Disoidei
413
Diamido A( ids
J38
Diluents
385
Dispai
413
Diammes
ns
Dnnethj lannne
385
Dispensaiy
413
Diannnin la
338
Dimethj 1 u sine
385
Dispensatoiy
413
Diapcdcsis
'138
Ihmotlu Ibenzene
385
Dispensing
413
Diaper
338
I )i mid Lite
385
Displacement
413
DuiphoretiLS
338
Dim pH>, Postaual
385
I )isposal
413
Diaplnagm
3*i9
Dnntioben/ine
385
1 Msposition
413
Diaphr.igm, Suigical A flec-
1 hnomama
385
1 >isscction-Wounds
413
tions of
341
Dnisd.ile-on-Tees
385
1 hssennnated
413
Diaphragmalgia
345
Dux-toplmne Gigas
385
Dissociation
413
Diaphragmatitis
345
Diodon
385
Dissolution
413
Diaphi agm.itocele
345
Diodont < ph.ilus
385
Dissolution, Lau of
413
Diaphthor.i
345
Dia'stium
385
Distal
414
Diaphysis
345
Diomn
385
Distempei
414
Diarihoca
345
Dioptie
385
Distichiasis
414
Diarthrosis
347
DioxylM'ii/ene
385
Distoma
414
Diascopic Method
347
Dio\ypuiin
385
Distomiib
414
Diastase
347
Ihplwllus
385
Dita I3ark
414
Diastasis
348
Diphtheria
385
Dittnch'b Plugs
414
Dias tomato-
348
Diphthoimu
400
Dimcidcs
414
Diastole
348
Diplac-usis
400
Dmiesis
414
Diastrophe
348
Diplegia
400
Diuretics
414
Diathesis ^
348
Dipleiual
400
Di ure tin
416
Diazobenzcne
349
Diploceph.il us
400
Dn.igation
416
Diazo-Itcaction
350
I hplococc'iis
400
Divalent
4J6
Diabasic Acids and Salts
350
Ihplouiiiia
400
Diveigence
416
Dibothrioccphalns Vul-
Ihploe
400
DIVPJ'H Paialysis
416
garis
350
Diplogenesw
400
Dneiticnlitis
416
Dicephalus
350
1 )iploma
400
Dueiticulum
416
Dicheilus
350
I >iplomyoha
400 A Divulsiou
• •
416
528
INDEX
I'AGH
Dizziness 416
Dobio's Line 416
Dochnuus Duodenahs 416
Docimasia 416
Dogs 416
Dohchocephaly 4 1 6
Dolichocnemic 416
Dohchohienc 416
Dohchopelhc 416
Drowsiness 423
Dnig Eruptions 423
Drug Habits . 432
Drummond - Morison
Operation 432
Drunkenness 433
Dry Labour 433
Dry Mouth 433
Dry ttot 433
PAC1B
Dyschozia . 437
Dyschromatopsia 437
Dyscmesia . 437
Dysorasia . 437
Dysdiachoresis . 437
Dysentery . 437
Dysgeuesis 450
Dysgcusia . 450
Dysidrosis 450
Dolor 416
Domestic Measures 416
Domicile, Law of 416
Donda Nduga 416
Donovan - Leishman
Dual Personality 433
Dublin's Disease 433
Dubominc 433
Duchcnne-Erb Paialysw 433
Ducicy's Bacillus 433
Dyskmesia 450'
Dyskyesis 450
Dyslaha 451
Dyslexia 451
Dysmcnorrhoca 451
Bodies . 416
Donovan's Solution 41 7
Dorema Ammoniacum 417
Duct or DuctiiH 133
Ductless (Jlands 433
Ductus Aiteuosus 433
Dysunmia 451
Dysmuesia 451
Dysmoiphia 451
Donmol H7
Ductus Venosus . 433
1 >ysiuyotoma 451
Dorsad 417
Duga's Test 433
Dysnusia 451
Dorsal 417
Duhrintr's Disease 433
Dysodia 451
Dor&o- 417
Dorsodyma 417
DuhrHsen's Operation 433
Dulcamara 433
Dysodontiasis 451
Dysootocia 451
Dosage 417
Dulcite 433
Dysorexia 451
Dotage 417
Dothienenteiitis 417
Double Consciousness 41 7
Double Monsteis 417
Double Vi&ion 417
Doubt, Insanity of 417
Dulnoss 433
Dumb Ague 133
Dumbness 433
Dum-Dum Fe\ei 433
Duodenitis 434
1 hiodeno- 434
Dysosmia 451
Dysostosis 451
Dyspaieunia 451
Dyspepsia 451
Dysphagia 451
Dysphasia 452
Douche 417
Douglas, Mechanism of 417
Douglas, Pouch of 417
Dourme 417
Dover's Powdei 417
" 1 )owsmg " Method 417
Dracontiasis 417
Dracontisomus 417
Dnodvuuui 434
Dupuytrcn's Contraction 435
Dupuyticn's Fracture 435
Dura Matci 435
Durande's Mixture 43r>
Durct's Balsam 135
Dmozioz's Sign 435
Dust-Discast's 435
Dysphoma 452
Dysphrasia 452
Dysphn'ina 452
Dyspnu-a 452
Dyssiaha 4">4
Dysspermatism 454
Dyssynodus 454
Dysthanasia 454
Drai'unculus 418
Dutton's Disease 435
Dystocia 454
Dragon's Blood 418
D\\arhsm 435
Dystopia 454
Drainage 41 §
Drastics 418
Dwellings 436
Dyad 436
Dystrophy 454
Dy&una 454
Draught 418
Dyaster Stage 436
Dreams 418
Dying Declaration 436
Ear-
Dressings 418
Dymal 436
Examination of 454
Drinkmg-('up 421
Drmking-Wiiter 421
Dynamite 436
Dynamomotei 436
Local Anesthetics 466
External Ear . 466
DroiUuch 421
Dromotherapy 421
Dynr 436
Dys- 436
Tympanic Membrane 480
Middle Kir-
Dromotropic 421
Dysacusis 437
Acute Inflammation 482
Drop 421
Diopsy 421
Dyscesthesia 437
Dysanagnosia 437
Chiomc Suppura-
tion 489
Dropsy, Epidemic 122
Diowning 423
Dysbasia Angio-Sclerotica
of Eib 437
Chrome Non-Sup-
purativc Disease 50H
END OF VOL 11
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